Healthcare Provider Details

I. General information

NPI: 1215266564
Provider Name (Legal Business Name): BROKEN BONE ORTHO CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 CALLE DE DIEGO STE 202 TORRE SAN FRANCISCO
SAN JUAN PR
00923-3004
US

IV. Provider business mailing address

PO BOX 366905
SAN JUAN PR
00936-6905
US

V. Phone/Fax

Practice location:
  • Phone: 787-756-6999
  • Fax: 787-765-7880
Mailing address:
  • Phone: 787-756-6999
  • Fax: 787-765-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4470
License Number StatePR

VIII. Authorized Official

Name: DR. RAFAEL OTERO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-756-6999