Healthcare Provider Details

I. General information

NPI: 1215900725
Provider Name (Legal Business Name): IVAN TERON-MENDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CALLE CONCEPCION VERA
MOCA PR
00676-5001
US

IV. Provider business mailing address

PO BOX 568
MOCA PR
00676-0568
US

V. Phone/Fax

Practice location:
  • Phone: 787-877-0615
  • Fax: 787-877-0615
Mailing address:
  • Phone: 787-207-8951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11671
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: