Healthcare Provider Details

I. General information

NPI: 1306880927
Provider Name (Legal Business Name): ALICE M ENCARNACION COLLAZO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 AVENIDA FELISA RINCON DE GAUTIER SUITE 202
SAN JUAN PR
00926-6675
US

IV. Provider business mailing address

702 CALLE ROOSEVELT SUITE 202
SAN JUAN PR
00907-3449
US

V. Phone/Fax

Practice location:
  • Phone: 787-999-0889
  • Fax: 787-999-0891
Mailing address:
  • Phone: 787-484-6943
  • Fax: 787-724-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8446
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: