=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568416659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO P. ACOSTA DUARTE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | B31 CALLE 4 URB. PASEO MAYOR
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-748-1063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1935 CALLE JULIO RUEDAS URB. BORINQUEN GARDENS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-590-5344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 5925
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------