=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114970316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NITZA M BERTRAN DOCTORATE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR. #3 KM. 25.7 SECTOR JUAN GONZALEZ
-----------------------------------------------------
City | RIO GRANDE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-887-5577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | COND. TIFFANY APT. 704 4939 AVE. ISLA VERDE
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00979-5406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-726-4677
-----------------------------------------------------
Fax | 787-887-5577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 11137
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------