Healthcare Provider Details

I. General information

NPI: 1134598337
Provider Name (Legal Business Name): OFICINA MEDICA PRIMARIA DEL SUR CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 INFANTERIA A1 LOCAL ANEXO REMA
YAUCO PR
00698
US

IV. Provider business mailing address

PO BOX 446
GUANICA PR
00653-0446
US

V. Phone/Fax

Practice location:
  • Phone: 787-992-7199
  • Fax: 787-992-7199
Mailing address:
  • Phone: 787-992-7199
  • Fax: 787-992-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16881
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15915
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE E GONZALEZ MORENO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-690-2644