Healthcare Provider Details

I. General information

NPI: 1982699559
Provider Name (Legal Business Name): JORGE MEJIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 AVE DE DIEGO
SAN JUAN PR
00909-1711
US

IV. Provider business mailing address

130 WINSTON CHURCHILL AVE PMB 364 SUITE 1
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-754-4244
  • Fax:
Mailing address:
  • Phone: 787-616-0032
  • Fax: 787-822-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13958
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: