Healthcare Provider Details

I. General information

NPI: 1235346438
Provider Name (Legal Business Name): GRUPO MEDICO IPA 555
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE SAN FRANCISCO 405 SUITE 2-C
SAN JUAN PR
00902
US

IV. Provider business mailing address

PO BOX 9023558
SAN JUAN PR
00902-3558
US

V. Phone/Fax

Practice location:
  • Phone: 787-721-0279
  • Fax: 787-721-0279
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. RAFAEL LUZARDO
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 787-721-0279