MEDICARE: DR. IVELISSE Y SAMBOLIN JESSURUN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	18136	PR
2	208100000X	Physical Medicine & Rehabilitation Physician	18136	PR

General Provider Information

NPI Number	:	1023202819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVELISSE Y SAMBOLIN JESSURUN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 368105
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00936-9105
Country	:	US
Telephone Number	:	787-550-3177
Fax Number	:	787-979-9005

Provider Business Practice Location Address
First Line	:	COND VICK CENTER C101
Second Line	:	AVE. MUNOZ RIVERA 806
City	:	RIO PIEDRAS
State	:	PR
Zip	:	00925-0001
Country	:	US
Telephone Number	:	787-767-7370
Fax Number	:	787-979-9005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	11/30/2016

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