=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194502567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLD STAR MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2023
-----------------------------------------------------
Last Update Date | 09/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 AVE LUIS MUNOZ MARIN
-----------------------------------------------------
City | HORMIGUEROS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00660-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-673-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 AVE LUIS MUNOZ MARIN
-----------------------------------------------------
City | HORMIGUEROS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00660-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-673-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | SHAHID M CHAUDHARY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-673-1238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------