=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144092677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUSTAVO ADOLFO INFANTE NERYS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2023
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 AVE GENERAL VALERO
-----------------------------------------------------
City | FAJARDO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00738-3998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-863-0505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14542
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00916-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-216-9291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 23606
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------