Provider Demographics
NPI:1104835073
Name:ASENJO, CONRADO W (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRADO
Middle Name:W
Last Name:ASENJO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:89 AVE DE DIEGO
Mailing Address - Street 2:SUITE 105 PMB-407
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-6372
Mailing Address - Country:US
Mailing Address - Phone:787-754-5091
Mailing Address - Fax:787-753-1783
Practice Address - Street 1:369 DE DIEGO AVE.
Practice Address - Street 2:TORRE SAN FRANCISCO SUITE 602
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00923-3005
Practice Address - Country:US
Practice Address - Phone:787-754-5091
Practice Address - Fax:787-753-1783
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR11874207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG-46682Medicare UPIN
PR89005Medicare ID - Type Unspecified