Healthcare Provider Details

I. General information

NPI: 1982924221
Provider Name (Legal Business Name): NELSON DOMINGO MATOS-LUCIANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. PONCE DE LEON, PDA. 37.5
SAN JUAN PR
00919
US

IV. Provider business mailing address

127 CALLE GUARAGUAO URB. MONTEHIEDRA
SAN JUAN PR
00926-7101
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20917
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: