=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235543190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONDOCANO INTERNAL MEDICINE PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 06/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE WASHINGTON # 29 ASHFORD MEDICAL CENTER SUITE 802
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00907-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-721-7973
-----------------------------------------------------
Fax | 787-721-7973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1359 CALLE LUCHETTI APT 802
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00907-2063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-721-7973
-----------------------------------------------------
Fax | 787-721-7973
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAFAEL BERMUDEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-721-7973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 12053
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------