Healthcare Provider Details

I. General information

NPI: 1639498132
Provider Name (Legal Business Name): HATO REY UROLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 AVE PONCE DE LEON SUITE 609 TORRE AUXILIO MUTUO
SAN JUAN PR
00917-5028
US

IV. Provider business mailing address

735 AVE PONCE DE LEON SUITE 609 TORRE AUXILIO MUTUO
SAN JUAN PR
00917-5028
US

V. Phone/Fax

Practice location:
  • Phone: 787-753-8533
  • Fax: 787-758-0373
Mailing address:
  • Phone: 787-753-8533
  • Fax: 787-758-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number3623
License Number StatePR

VIII. Authorized Official

Name: JUAN I MEDINA
Title or Position: PARTNER
Credential: MD
Phone: 787-753-8533