Healthcare Provider Details

I. General information

NPI: 1205693777
Provider Name (Legal Business Name): OMAR ISMAEL MORALES ROSARIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/02/2024
Certification Date: 03/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VISTAS DE RIO GRANDE II #476 CALLE REINA DE LAS FLORES
RIO GRANDE PR
00745
US

IV. Provider business mailing address

VISTAS DE RIO GRANDE II #476 CALLE REINA DE LAS FLORES
RIO GRANDE PR
00745
US

V. Phone/Fax

Practice location:
  • Phone: 787-242-2861
  • Fax:
Mailing address:
  • Phone: 787-242-2861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: