Healthcare Provider Details

I. General information

NPI: 1124039813
Provider Name (Legal Business Name): LEONARDO RAFAEL HORMAZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 CALLE SAN JORGE SUIE 2B
SANTURCE PR
00912-3307
US

IV. Provider business mailing address

274 DORADO BCH E
DORADO PR
00646-2213
US

V. Phone/Fax

Practice location:
  • Phone: 787-999-9450
  • Fax:
Mailing address:
  • Phone: 787-727-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-115444
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number15346
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code2080T0004X
TaxonomyPediatric Transplant Hepatology Physician
License Number15346
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: