Healthcare Provider Details

I. General information

NPI: 1649525874
Provider Name (Legal Business Name): PROSPERITUS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CARR 176 APT 605
SAN JUAN PR
00926-6680
US

IV. Provider business mailing address

400 CARR 176 APT 605
SAN JUAN PR
00926-6680
US

V. Phone/Fax

Practice location:
  • Phone: 787-529-1699
  • Fax:
Mailing address:
  • Phone: 787-529-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2903
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number17586
License Number StatePR

VIII. Authorized Official

Name: DR. HIRAM D ORTEGA
Title or Position: PRESIDENT
Credential: M.D
Phone: 787-529-1699