Healthcare Provider Details

I. General information

NPI: 1770061699
Provider Name (Legal Business Name): MAYRA OSEGUERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF PUERTO RICO/RECINTO DE CIENCIAS MEDICAS
SAN JUAN PR
00936
US

IV. Provider business mailing address

2003 WELWYN AVE
DES PLAINES IL
60018-3138
US

V. Phone/Fax

Practice location:
  • Phone: 847-337-7451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14777I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: