Healthcare Provider Details

I. General information

NPI: 1245231497
Provider Name (Legal Business Name): GASTRO MED DEL SUR, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 AVE. TITO CASTRO SUITE 518 TORRE MEDICA SAN LUCAS
PONCE PR
00716-4721
US

IV. Provider business mailing address

909 AVE. TITO CASTRO SUITE 518 TORRE MEDICA SAN LUCAS
PONCE PR
00716-4721
US

V. Phone/Fax

Practice location:
  • Phone: 787-290-2948
  • Fax: 787-841-4832
Mailing address:
  • Phone: 787-290-2948
  • Fax: 787-841-4832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8042
License Number StatePR

VIII. Authorized Official

Name: MRS. CARMEN L. SANTIAGO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-290-2948