Healthcare Provider Details

I. General information

NPI: 1871663765
Provider Name (Legal Business Name): RENAN A. DIEPPA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 S.E. 42ND STREET REPARTO METROPOLITANO
SAN JUAN PR
00921
US

IV. Provider business mailing address

PO BOX 363704
SAN JUAN PR
00936-3704
US

V. Phone/Fax

Practice location:
  • Phone: 787-751-3535
  • Fax: 787-767-6111
Mailing address:
  • Phone: 787-751-3535
  • Fax: 787-767-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number05711
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number5711
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: