MEDICARE: LUIS BAEZ VALLECILLO MD

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	207R00000X	Internal Medicine Physician	19615	PR
2	207R00000X	Internal Medicine Physician	P6580	TX
3	207RH0003X	Hematology & Oncology Physician	19615	PR

General Provider Information

NPI Number	:	1265788855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS BAEZ VALLECILLO MD

Provider Business Mailing Address
First Line	:	97 AVE DE DIEGO
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00927-6310
Country	:	US
Telephone Number	:	787-919-7919
Fax Number	:	787-919-7918

Provider Business Practice Location Address
First Line	:	97 AVE DE DIEGO
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00927-6310
Country	:	US
Telephone Number	:	939-545-6353
Fax Number	:	939-545-6354

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

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	09/19/2022

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