Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 14476 | PR |
NPI | 1023059383 |
---|---|
Provider Name | Ivelisse Burgos |
First Address | Toa Alta, PR 00953-4926 |
Second Address | Comerio, PR 00782-2539 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 09/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
21087 | TRIPLE S (01) | PR |
H695003 | (02) | PR |