=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568683852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE E SERRA-GAZTAMBIDE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HOSPITAL INDUSTRIAL-CENTRO MEDICO BO. MONACILLOS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-754-2525
-----------------------------------------------------
Fax | 787-767-3968
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MONTEATENAS RR36 BOX 60
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-760-1294
-----------------------------------------------------
Fax | 787-767-3968
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | 7946
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------