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General NPI Number Information
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NPI Number | 1114186814
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Entity Type | Organization
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Legal Business Name | LA PLATA MEDICAL GROUP
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Dates
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Enumeration Date | 06/06/2008
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Last Update Date | 06/06/2008
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Provider Practice Location Address
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Address Line | A4 CALLE VILLA MARIA C/LEOPOLDO DIAZ #1
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City | TOA ALTA
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State | PR
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Zip | 00953-2301
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Country | US
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Telephone | 787-870-1272
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 716
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City | DORADO
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State | PR
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Zip | 00646-0716
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Country | US
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Telephone | 787-870-1272
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VICTOR M BURGOS
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Credential | M.D.
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Telephone | 787-870-1272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 5589
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License Number State | PR
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