Healthcare Provider Details

I. General information

NPI: 1942294012
Provider Name (Legal Business Name): INSTITUTO DE GASTROENTEROLOGIA DE P.R.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE F.D. ROOSEVELT AVE. SUITE 206
SAN JUAN PR
00918
US

IV. Provider business mailing address

400 AVE F.D, ROOSEVELT AVE. SUITE 206
SAN JUAN PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-764-8787
  • Fax: 787-250-1029
Mailing address:
  • Phone: 787-764-8787
  • Fax: 787-250-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StatePR

VIII. Authorized Official

Name: MR. PRUDENCIO A. LAUREANO
Title or Position: ADMINISTRATOR
Credential: M.H.S.A.
Phone: 787-764-8787