=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922066018
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE A GRATACOS F.A.C.O.G
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SAN JORGE MEDICAL OFFICE BUILDING CALLE SAN JORGE 252 SUITE 201
-----------------------------------------------------
City | SANTURCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-727-5252
-----------------------------------------------------
Fax | 787-727-5200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16457
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00908-6457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-727-5252
-----------------------------------------------------
Fax | 787-727-5200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4775
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------