Healthcare Provider Details

I. General information

NPI: 1316936404
Provider Name (Legal Business Name): ISRAEL ANTONIO CORDERO-VALLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CALLE SAN CARLOS
QUEBRADILLAS PR
00678-1775
US

IV. Provider business mailing address

PO BOX 974
QUEBRADILLAS PR
00678-0974
US

V. Phone/Fax

Practice location:
  • Phone: 787-895-4121
  • Fax: 787-895-8059
Mailing address:
  • Phone: 787-895-4121
  • Fax: 787-895-8059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9317
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: