Healthcare Provider Details

I. General information

NPI: 1184705568
Provider Name (Legal Business Name): EGIDIO MONTANILE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 FERNADEZ JUNCOS AVE. SUITE 1A
SANTURCE PR
00909
US

IV. Provider business mailing address

PO BOX 19657
SAN JUAN PR
00910-1657
US

V. Phone/Fax

Practice location:
  • Phone: 787-724-0871
  • Fax: 787-724-0886
Mailing address:
  • Phone: 787-724-0871
  • Fax: 787-724-0886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0039
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: