Provider Demographics
NPI:1003997206
Name:CONSULTORIO OTO CCC PSC
Entity Type:Organization
Organization Name:CONSULTORIO OTO CCC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:ORTIZ ROSARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-844-5121
Mailing Address - Street 1:PO BOX 1435
Mailing Address - Street 2:
Mailing Address - City:JUANA DIAZ
Mailing Address - State:PR
Mailing Address - Zip Code:00795-1435
Mailing Address - Country:US
Mailing Address - Phone:787-844-5121
Mailing Address - Fax:787-842-5796
Practice Address - Street 1:AVE TORRE SAN CRISTOBAL
Practice Address - Street 2:SUITE 205 A
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-844-5121
Practice Address - Fax:787-842-5796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9602174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE01284Medicare UPIN
PR0085224Medicare PIN