=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912076209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICARDO VALLEJO RIVERA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 06/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 CALLE GAUTIER BENITEZ CONSOLIDATED MEDICAL PLAZA OFFICE 104
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-5527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-746-8383
-----------------------------------------------------
Fax | 787-743-5484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 CALLE GAUTIER BENITEZ CONSOLIDATED MEDICAL PLAZA SUITE 004
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-5527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-746-8383
-----------------------------------------------------
Fax | 787-743-5484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 011550
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------