Healthcare Provider Details

I. General information

NPI: 1295896587
Provider Name (Legal Business Name): FAJARDO IMAGING MRI CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE AGUSTIN PEREZ ANDINO B-30 VILLAS DE RIO GRANDE
RIO GRANDE PR
00745
US

IV. Provider business mailing address

PO BOX 490
PUERTO REAL PR
00740
US

V. Phone/Fax

Practice location:
  • Phone: 787-887-5944
  • Fax: 787-887-7917
Mailing address:
  • Phone: 787-860-3400
  • Fax: 787-863-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number5767
License Number StatePR

VIII. Authorized Official

Name: DR. DIANA FERNADEZ GARCIA
Title or Position: RADIOLOGIST
Credential: M.D.
Phone: 787-860-3400