Healthcare Provider Details

I. General information

NPI: 1467110759
Provider Name (Legal Business Name): EDGAR CAMPOS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 10/19/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLINICA LAS AMERICAS 400 AVENIDA F.D. ROOSEVEL
SAN JUAN PR
00936
US

IV. Provider business mailing address

COLINAS DE SAN MARTIN C9 CALLE 4
JUANA DIAZ PR
00795
US

V. Phone/Fax

Practice location:
  • Phone: 939-439-8163
  • Fax:
Mailing address:
  • Phone: 939-439-8163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7127
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7127
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: