=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598788408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE RAFAEL PESQUERA-GARCIA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 12/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SANTURCE MEDICAL MALL SUITE #309-310 AVE. PONCE DE LEON 1801
-----------------------------------------------------
City | SANTURCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-728-1193
-----------------------------------------------------
Fax | 787-726-4244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19921
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-728-1193
-----------------------------------------------------
Fax | 787-726-4244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 7279
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------