Provider Demographics
NPI:1114935061
Name:JUSINO-MCDOUGALL, ISMAEL ENRIQUE (MD)
Entity Type:Individual
Prefix:MR
First Name:ISMAEL
Middle Name:ENRIQUE
Last Name:JUSINO-MCDOUGALL
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 1038
Mailing Address - Street 2:13 DE MARZO ST #19
Mailing Address - City:GUANICA
Mailing Address - State:PR
Mailing Address - Zip Code:00653-1038
Mailing Address - Country:US
Mailing Address - Phone:787-821-2879
Mailing Address - Fax:787-821-2879
Practice Address - Street 1:13 DE MARZO ST
Practice Address - Street 2:#19
Practice Address - City:GUANICA
Practice Address - State:PR
Practice Address - Zip Code:00653-1038
Practice Address - Country:US
Practice Address - Phone:787-821-2879
Practice Address - Fax:787-821-2879
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5960208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
27214OtherSSS
0027214Medicare ID - Type Unspecified
27214OtherSSS