Healthcare Provider Details

I. General information

NPI: 1356421549
Provider Name (Legal Business Name): BIDOT PREVENTIVE MEDICINE CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 CALLE EDUARDO RIERA
MAYAGUEZ PR
00680-3811
US

IV. Provider business mailing address

67 CALLE EDUARDO RIERA
MAYAGUEZ PR
00680-3811
US

V. Phone/Fax

Practice location:
  • Phone: 787-265-4610
  • Fax:
Mailing address:
  • Phone: 787-265-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number9542
License Number StatePR

VIII. Authorized Official

Name: MRS. MAYRA D BIDOT
Title or Position: DIRECTOR
Credential: MD
Phone: 787-265-4610