Healthcare Provider Details

I. General information

NPI: 1417095944
Provider Name (Legal Business Name): OTOLOGIC PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55E DE DIEGO ST. SUITE 105, CPR PROFESSIONAL BLDG.
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 6428
MAYAGUEZ PR
00781-6428
US

V. Phone/Fax

Practice location:
  • Phone: 787-833-2155
  • Fax: 787-833-2680
Mailing address:
  • Phone: 787-833-2155
  • Fax: 787-833-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number11064
License Number StatePR

VIII. Authorized Official

Name: MIGUEL A. LASALLE
Title or Position: DUENO
Credential: MD
Phone: 787-833-2155