=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962507509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTO DE PODIATRIA Y PIE DIABETICO DE PUERTO RICO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 05/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1494 AVE FD ROOSEVELT SUITE 101
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00920-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-782-1453
-----------------------------------------------------
Fax | 787-273-1452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1494 AVE FD ROOSEVELT SUITE 101
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00920-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-782-1453
-----------------------------------------------------
Fax | 787-273-1452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CARLOS IVAN ARROYO
-----------------------------------------------------
Credential | D.P.M
-----------------------------------------------------
Telephone | 787-782-1453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number | 0094
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------