Healthcare Provider Details

I. General information

NPI: 1972651693
Provider Name (Legal Business Name): CENTRO DE GASTROENTEROLOGIA PEDIATRICA DEL OESTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CALLE DR BASORA N OFFICE 212
MAYAGUEZ PR
00680-4810
US

IV. Provider business mailing address

PO BOX 3224
MAYAGUEZ PR
00681-3224
US

V. Phone/Fax

Practice location:
  • Phone: 787-805-5830
  • Fax: 787-805-6430
Mailing address:
  • Phone: 787-805-5830
  • Fax: 787-805-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number10620
License Number StatePR

VIII. Authorized Official

Name: MARIA J RODRIGUEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-805-6868