Healthcare Provider Details

I. General information

NPI: 1912333527
Provider Name (Legal Business Name): RADA UROLOGICAL CONSULTING PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 CALLE 42 SE REPARTO METROPOLITANO
SAN JUAN PR
00921-2701
US

IV. Provider business mailing address

PO BOX 363704
SAN JUAN PR
00936-3704
US

V. Phone/Fax

Practice location:
  • Phone: 787-751-3535
  • Fax: 787-767-6111
Mailing address:
  • Phone: 787-751-3535
  • Fax: 787-767-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number StatePR

VIII. Authorized Official

Name: RENAN ARIEL DIEPPA
Title or Position: OWNER
Credential: M.D.
Phone: 787-751-3535