Healthcare Provider Details

I. General information

NPI: 1790394286
Provider Name (Legal Business Name): GRETCHEN LORRAINE NIEVES-BURGOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CONCILIO DE SALUD INTEGRAL DE LOIZA CARR #188 INT #187
LOIZA PR
00772
US

IV. Provider business mailing address

PO BOX 365067
SAN JUAN PR
00936-5067
US

V. Phone/Fax

Practice location:
  • Phone: 787-876-2042
  • Fax:
Mailing address:
  • Phone: 787-758-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23848
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: