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General NPI Number Information
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NPI Number | 1386903573
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Entity Type | Organization
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Legal Business Name | MB DERMATOLOGY, PSC
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Dates
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Enumeration Date | 05/09/2012
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Last Update Date | 05/09/2012
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Provider Practice Location Address
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Address Line | CENTRO INTERNACIONAL DE MERCADEO, TOWER 1, SUITE 304 ROAD 165 PR-28
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City | GUAYNABO
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State | PR
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Zip | 00968
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Country | US
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Telephone | 787-705-8887
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Fax | 787-705-8886
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Provider Business Mailing Address
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Address Line | PMB 705, 89 DE DIEGO AVE. SUITE 105
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City | SAN JUAN
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State | PR
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Zip | 00927-6320
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Country | US
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Telephone | 787-705-8887
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Fax | 787-705-8886
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Authorized Official
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Title or Position | DERMATOLOGIST/OWNER
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Name | DR. MAYRA C BEAUCHAMP
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Credential | MD
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Telephone | 787-630-1369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 17621
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License Number State | PR
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