Provider Demographics
NPI:1033116264
Name:FRAGA BERRIOS, IVONNE DE L (MD)
Entity Type:Individual
Prefix:DR
First Name:IVONNE DE L
Middle Name:
Last Name:FRAGA BERRIOS
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:PMB 191 PO BOX 7891
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-7891
Mailing Address - Country:US
Mailing Address - Phone:787-708-4618
Mailing Address - Fax:
Practice Address - Street 1:708 AVE PONCE DE LEON
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-4502
Practice Address - Country:US
Practice Address - Phone:787-763-9312
Practice Address - Fax:787-294-1246
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR131622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20101OtherSSS PROVIDER #
PRH82111Medicare UPIN
PR20101OtherSSS PROVIDER #