Healthcare Provider Details

I. General information

NPI: 1548645468
Provider Name (Legal Business Name): CDT CENTRO DE MEDICINA PRIMARIA DE VEGA ALTA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CALLE LUIS MUNOZ RIVERA
VEGA ALTA PR
00692
US

IV. Provider business mailing address

3 CALLE LUIS MUNOZ RIVERA
VEGA ALTA PR
00692
US

V. Phone/Fax

Practice location:
  • Phone: 787-883-0124
  • Fax: 787-883-0222
Mailing address:
  • Phone: 787-883-0124
  • Fax: 787-883-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number53353
License Number StatePR

VIII. Authorized Official

Name: DR. MILDALIAS DOMINGUEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-883-0124