Healthcare Provider Details

I. General information

NPI: 1336101112
Provider Name (Legal Business Name): ROOSEVELT PEDIATRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 CALLE CESAR GONZALEZ SUITE 404
SAN JUAN PR
00918-3756
US

IV. Provider business mailing address

576 CALLE CESAR GONZALEZ SUITE 404
SAN JUAN PR
00918-3756
US

V. Phone/Fax

Practice location:
  • Phone: 787-753-1097
  • Fax: 787-764-3927
Mailing address:
  • Phone: 787-753-1097
  • Fax: 787-764-3927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCO ANTONIO PEREZ-DAVILA
Title or Position: SENIOR PARTNER
Credential: M.D.
Phone: 787-753-1097