Healthcare Provider Details

I. General information

NPI: 1952953481
Provider Name (Legal Business Name): LAURA TERESA DOMENECH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 CALLE MONTERREY
PONCE PR
00716-0377
US

IV. Provider business mailing address

PO BOX 7004
PONCE PR
00732-7004
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-2505
  • Fax:
Mailing address:
  • Phone: 787-840-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13246
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: