Provider Demographics
NPI:1043216401
Name:CONAWAY LANUZA, RALPH C (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:C
Last Name:CONAWAY LANUZA
Suffix:
Gender:M
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 362309
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-2309
Mailing Address - Country:US
Mailing Address - Phone:787-763-9468
Mailing Address - Fax:787-767-5003
Practice Address - Street 1:AVE ROOSEVELT # 400 CLINICA LAS AMERICA SUITE 203
Practice Address - Street 2:
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00918-0000
Practice Address - Country:US
Practice Address - Phone:787-763-9468
Practice Address - Fax:787-767-5003
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2017-02-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-20
Provider Licenses
StateLicense IDTaxonomies
PR4357174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD83312Medicare UPIN
PR0026719Medicare PIN
PR0080073AMedicare PIN