Provider Demographics
NPI:1043223506
Name:LARRAURI RENTA, JOSE JESUS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:JESUS
Last Name:LARRAURI RENTA
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 1883
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-1883
Mailing Address - Country:US
Mailing Address - Phone:787-825-1224
Mailing Address - Fax:787-825-0763
Practice Address - Street 1:1 CALLE MARIO BRASCHI
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-2501
Practice Address - Country:US
Practice Address - Phone:787-825-1224
Practice Address - Fax:787-825-0763
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7382208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D08472Medicare UPIN
PR0028745Medicare ID - Type Unspecified