Healthcare Provider Details

I. General information

NPI: 1891104188
Provider Name (Legal Business Name): SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TORRE MED SAN LUCAS AVE. TITO CASTRO
PONCE PR
00716-4728
US

IV. Provider business mailing address

PO BOX 2000 PMB 137
MERCEDITA PR
00715
US

V. Phone/Fax

Practice location:
  • Phone: 787-290-3333
  • Fax: 787-290-4444
Mailing address:
  • Phone: 787-290-3333
  • Fax: 787-290-4444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number13247
License Number StatePR

VIII. Authorized Official

Name: DR. EDGAR DOMENECH FAGUNDO
Title or Position: OWNER
Credential: MD
Phone: 787-290-3333