Healthcare Provider Details

I. General information

NPI: 1124088224
Provider Name (Legal Business Name): MIGUEL A DE JESUS MD, FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND ADA LIGIA LOCAL B OFICINA 4 AVE ASHFORD 1452
SAN JUAN PR
00907-1581
US

IV. Provider business mailing address

CALLE 1 #10 EXTENSION ALTURAS DE SAN PATRICIO
GUAYNABO PR
00968
US

V. Phone/Fax

Practice location:
  • Phone: 787-640-7111
  • Fax:
Mailing address:
  • Phone: 787-725-0909
  • Fax: 787-725-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5765
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: