=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538143136
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ESCOBAR MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | INGENIO STR #180
-----------------------------------------------------
City | TOA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-794-4718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | A10STR- H14A VAN SCOY
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-799-1710
-----------------------------------------------------
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 | 016021
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------