Healthcare Provider Details

I. General information

NPI: 1326257197
Provider Name (Legal Business Name): MAGDA FIDALGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO. MONACILLO CENTRO MEDICO HOSPITAL SAN JUAN
SAN JUAN PR
00928
US

IV. Provider business mailing address

PMB 668 #138 AVE. WINSTON CHURCHILL
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-765-0521
  • Fax:
Mailing address:
  • Phone: 787-599-3192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14970
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: