Healthcare Provider Details

I. General information

NPI: 1275829459
Provider Name (Legal Business Name): HERIBERTO CASANOVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 06/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CALLE GEORGETOWN
SAN JUAN PR
00927-4018
US

IV. Provider business mailing address

300 CALLE GEORGETOWN
SAN JUAN PR
00927-4018
US

V. Phone/Fax

Practice location:
  • Phone: 305-772-5550
  • Fax:
Mailing address:
  • Phone: 305-772-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12855-I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: