Provider Demographics
NPI:1023202819
Name:SAMBOLIN JESSURUN, IVELISSE Y (MD)
Entity Type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:Y
Last Name:SAMBOLIN JESSURUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368105
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-9105
Mailing Address - Country:US
Mailing Address - Phone:787-550-3177
Mailing Address - Fax:787-979-9005
Practice Address - Street 1:COND VICK CENTER C101
Practice Address - Street 2:AVE. MUNOZ RIVERA 806
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00925-0001
Practice Address - Country:US
Practice Address - Phone:787-767-7370
Practice Address - Fax:787-979-9005
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18136208D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice