Healthcare Provider Details

I. General information

NPI: 1164835625
Provider Name (Legal Business Name): SAMARI ROMAN GANDULLA & ASOCIADOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1452 AVE ASHFORD 408 ADA LIGIA
SAN JUAN PR
00907-1581
US

IV. Provider business mailing address

1452 AVE ASHFORD 408 ADA LIGIA
SAN JUAN PR
00907-1581
US

V. Phone/Fax

Practice location:
  • Phone: 787-509-7212
  • Fax:
Mailing address:
  • Phone: 787-509-7212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StatePR

VIII. Authorized Official

Name: SAMARI ROMAN GANDULLA
Title or Position: PRESIDENTA
Credential: M.D.
Phone: 787-649-7212