Healthcare Provider Details

I. General information

NPI: 1841669066
Provider Name (Legal Business Name): OCCUMED HEALTH SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 AVE FD ROOSEVELT
SAN JUAN PR
00918-2305
US

IV. Provider business mailing address

305 AVE FD ROOSEVELT
SAN JUAN PR
00918-2305
US

V. Phone/Fax

Practice location:
  • Phone: 787-772-0707
  • Fax: 787-772-0711
Mailing address:
  • Phone: 787-772-0707
  • Fax: 787-772-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22354
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number15483
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number15483
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15483
License Number StatePR

VIII. Authorized Official

Name: DR. WILFREDO JOSE AVILES-MALDONADO
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 787-772-0707