Healthcare Provider Details

I. General information

NPI: 1154314292
Provider Name (Legal Business Name): SOUTHERN RETINA CONSULTANTS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 AVE TITO CASTRO SUITE 709
PONCE PR
00716-4728
US

IV. Provider business mailing address

PO BOX 801089
COTO LAUREL PR
00780-1089
US

V. Phone/Fax

Practice location:
  • Phone: 787-842-2512
  • Fax: 787-840-6966
Mailing address:
  • Phone: 787-842-2512
  • Fax: 787-840-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number11622
License Number StatePR

VIII. Authorized Official

Name: DR. JORGE H GUTIERREZ-DORRINGTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-842-2512