Healthcare Provider Details

I. General information

NPI: 1346499746
Provider Name (Legal Business Name): IVAN J ELIAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 CALLE ENCARNACION
SAN JUAN PR
00920-4744
US

IV. Provider business mailing address

1604 CALLE ENCARNACION
SAN JUAN PR
00920-4744
US

V. Phone/Fax

Practice location:
  • Phone: 787-793-8689
  • Fax:
Mailing address:
  • Phone: 787-793-8689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2853
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: