Provider Demographics
NPI:1124411913
Name:SUBERVI, IVAN OSCAR
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:OSCAR
Last Name:SUBERVI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE 1, LOTE 18
Mailing Address - Street 2:METRO OFFICE PARK SUITE 400
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968
Mailing Address - Country:US
Mailing Address - Phone:787-774-3344
Mailing Address - Fax:
Practice Address - Street 1:CARR.#5 AVE CENTRAL JUANITA FINAL
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00960
Practice Address - Country:US
Practice Address - Phone:939-225-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19924207P00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry