Healthcare Provider Details

I. General information

NPI: 1760645105
Provider Name (Legal Business Name): GASTROENTEROLOGIA AVANZADA DEL CARIBE,C.S.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 EAST DE DIEGO STREET, C.P.R. PROF. BLDG. SUITE 104
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 3146
MAYAGUEZ PR
00681-3146
US

V. Phone/Fax

Practice location:
  • Phone: 787-265-4250
  • Fax: 787-265-4290
Mailing address:
  • Phone: 787-265-4250
  • Fax: 787-265-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12853
License Number StatePR

VIII. Authorized Official

Name: MRS. ANA MARIA LOPEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-265-4250