Healthcare Provider Details

I. General information

NPI: 1598701724
Provider Name (Legal Business Name): MARCOS ANTONIO JUSTINANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZA GABRIELA BO. CANAS CARR. 132 KM 22.1
PONCE PR
00728
US

IV. Provider business mailing address

1575 AVE MUNOZ RIVERA PMB 250
PONCE PR
00717-0211
US

V. Phone/Fax

Practice location:
  • Phone: 787-812-3930
  • Fax: 787-812-3931
Mailing address:
  • Phone: 787-644-6323
  • Fax: 787-644-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12205
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: