Healthcare Provider Details

I. General information

NPI: 1790070266
Provider Name (Legal Business Name): J.M. UROLOGY, C.S.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 AVE PONCE DE LEON .609 TORRE AUXILIO MUTUO
SAN JUAN PR
00917-5022
US

IV. Provider business mailing address

735 AVE PONCE DE LEON .609 TORRE AUXILIO MUTUO
SAN JUAN PR
00917-5022
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 Code302R00000X
TaxonomyHealth Maintenance Organization
License Number11756
License Number StatePR

VIII. Authorized Official

Name: MR. JUAN J MEDINA
Title or Position: PRESIDENT
Credential: M.D.,
Phone: 787-753-8533