Healthcare Provider Details

I. General information

NPI: 1922343144
Provider Name (Legal Business Name): MOH PEDS OTO CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 CALLE SAN JORGE STE 501 SAN JORGE MEDICAL BUILDING
SAN JUAN PR
00912-3241
US

IV. Provider business mailing address

PO BOX 362707
SAN JUAN PR
00936-2707
US

V. Phone/Fax

Practice location:
  • Phone: 787-268-2300
  • Fax: 787-268-3055
Mailing address:
  • Phone: 787-268-2300
  • Fax: 787-268-3055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. MELISSA ORTIZ HERNANDEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-268-2300