Healthcare Provider Details

I. General information

NPI: 1316942956
Provider Name (Legal Business Name): HATO REY MEDICAL GASTRO,CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 AVE PONCE DE LEON STE 809 TORRE MEDICA AUXILIO MUTUO
SAN JUAN PR
00917-5031
US

IV. Provider business mailing address

735 AVE PONCE DE LEON STE 809 TORRE MEDICA AUXILIO MUTUO
SAN JUAN PR
00917-5031
US

V. Phone/Fax

Practice location:
  • Phone: 787-274-1282
  • Fax: 787-764-0898
Mailing address:
  • Phone: 787-274-1282
  • Fax: 787-764-0898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12594
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number15480
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number7165
License Number StatePR

VIII. Authorized Official

Name: MR. JOSE C JIMENEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-274-1282