Healthcare Provider Details

I. General information

NPI: 1093016453
Provider Name (Legal Business Name): MAYAGUEZ SURGICAL JUSTINIANO SURIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MENDEZ VIGO 109 ESTE
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 3049
MAYAGUEZ PR
00681-3049
US

V. Phone/Fax

Practice location:
  • Phone: 787-834-7740
  • Fax: 787-833-0868
Mailing address:
  • Phone: 787-833-5613
  • Fax: 787-833-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number7142
License Number StatePR

VIII. Authorized Official

Name: DR. JORGE JUSTINIANO
Title or Position: GENERAL PARTNER
Credential: M.D.
Phone: 787-833-0868