Healthcare Provider Details

I. General information

NPI: 1407872104
Provider Name (Legal Business Name): JESUS MANUEL MARIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CASIA STREET
SAN JUAN PR
00921-3201
US

IV. Provider business mailing address

1771 CALLE ALABAMA SAN GERARDO
SAN JUAN PR
00926-3451
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-7582
  • Fax: 787-641-8369
Mailing address:
  • Phone: 787-764-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number13095
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: