MEDICARE: DR. MARICARMEN GRAJALES SAN MIGUEL 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	12524I	PR

General Provider Information

NPI Number	:	1891090890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARICARMEN GRAJALES SAN MIGUEL M.D.

Provider Business Mailing Address
First Line	:	1688 CALLE MANZANILLO
Second Line	:	VENUS GARDENS
City	:	SAN JUAN
State	:	PR
Zip	:	00926-4634
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1688 CALLE MANZANILLO
Second Line	:	VENUS GARDENS
City	:	SAN JUAN
State	:	PR
Zip	:	00926-4634
Country	:	US
Telephone Number	:	787-617-0900
Fax Number	:

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

Provider Enumeration Date	:	01/21/2011
Last Update Date	:	01/21/2011

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