Provider Demographics
NPI:1164525465
Name:NEGRON AGOSTO, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:NEGRON AGOSTO
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 1666
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-1666
Mailing Address - Country:US
Mailing Address - Phone:787-801-4698
Mailing Address - Fax:787-801-4698
Practice Address - Street 1:CALLE CIPRES #706 LOCAL #2
Practice Address - Street 2:FAJARDO GARDENS
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-801-4698
Practice Address - Fax:787-801-4698
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11991208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH05544Medicare UPIN
PR90303Medicare PIN