Provider Demographics
NPI:1154467744
Name:CARRASQUILLO, WALDEMAR (DC)
Entity Type:Individual
Prefix:DR
First Name:WALDEMAR
Middle Name:
Last Name:CARRASQUILLO
Suffix:
Gender:M
Credentials:DC
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 363374
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-3374
Mailing Address - Country:US
Mailing Address - Phone:787-765-8494
Mailing Address - Fax:787-765-5552
Practice Address - Street 1:65TH INFANTRY AVE.
Practice Address - Street 2:390
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-1806
Practice Address - Country:US
Practice Address - Phone:787-765-8494
Practice Address - Fax:787-765-5552
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR263111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor