Healthcare Provider Details

I. General information

NPI: 1871026237
Provider Name (Legal Business Name): JORGE LUIS RULLAN GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CASIA
SAN JUAN PR
00921-3200
US

IV. Provider business mailing address

10 CALLE CASIA
SAN JUAN PR
00921-3200
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-7582
  • Fax: 787-641-4555
Mailing address:
  • Phone: 787-641-7582
  • Fax: 787-641-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number101970
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21305
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: