Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 3196 | PR |
NPI | 1003808890 |
---|---|
Provider Name | Dr. Radames C Marin Roman SR. |
First Address | Yauco, PR 00698-1665 |
Second Address | Yauco, PR 00698 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2005 |
Last Update Date | 29/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C79289 | (02) | PR |