Provider Demographics
NPI:1124591243
Name:CAMERON, DORIAN BRUNO
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:BRUNO
Last Name:CAMERON
Suffix:
Gender:F
Credentials:
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 193
Mailing Address - Street 2:
Mailing Address - City:GARROCHALES
Mailing Address - State:PR
Mailing Address - Zip Code:00652-0193
Mailing Address - Country:US
Mailing Address - Phone:787-996-7816
Mailing Address - Fax:
Practice Address - Street 1:CARR 683 KM 1.3 INTERIOR FACTOR 1
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00652-0193
Practice Address - Country:US
Practice Address - Phone:787-996-7816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR80031510876Medicaid