Healthcare Provider Details

I. General information

NPI: 1841534823
Provider Name (Legal Business Name): LISANDRA CORDERO NIEVES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PR 505 KM 1.0 URB GLENVIEW GARDENS GLENVIEW GARDENS SHOPPING CENTER LOCAL #4
PONCE PR
00731
US

IV. Provider business mailing address

P O BOX 102
MERCEDITA PR
00715
US

V. Phone/Fax

Practice location:
  • Phone: 787-812-3153
  • Fax:
Mailing address:
  • Phone: 787-812-3153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number19375
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: