Provider Demographics
NPI:1114186814
Name:LA PLATA MEDICAL GROUP
Entity Type:Organization
Organization Name:LA PLATA MEDICAL GROUP
Other - Org Name:LA PLATA MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-870-1272
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-0716
Mailing Address - Country:US
Mailing Address - Phone:787-870-1272
Mailing Address - Fax:
Practice Address - Street 1:A4 CALLE VILLA MARIA
Practice Address - Street 2:C/LEOPOLDO DIAZ #1
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-2301
Practice Address - Country:US
Practice Address - Phone:787-870-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA PLATA MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5589302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR9600020OtherJORGE L SANCHEZ TORRES
PR9120018OtherOTTO RIOS DONES
PR7190010OtherJUAN C ECHEANDIA
PR7580034OtherVICTOR M BURGOS RIVERA