Healthcare Provider Details

I. General information

NPI: 1033103320
Provider Name (Legal Business Name): MIGUEL P. CARDONA CANCIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 PONCE DE LEON AVE. EDIF. METROPOLIS SUITE 102
SAN JUAN PR
00917-3403
US

IV. Provider business mailing address

419 PONCE DE LEON AVE. EDIF. METROPOLIS SUITE 102
SAN JUAN PR
00917-3403
US

V. Phone/Fax

Practice location:
  • Phone: 787-754-0725
  • Fax: 787-622-3490
Mailing address:
  • Phone: 787-754-0725
  • Fax: 787-622-3490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number11591
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number11591
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number11591
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number11591
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: