Provider Demographics
NPI:1174007470
Name:COSTA ESTE MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:COSTA ESTE MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ISMARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:787-646-7769
Mailing Address - Street 1:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:LUQUILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00773-1001
Mailing Address - Country:US
Mailing Address - Phone:787-860-3700
Mailing Address - Fax:787-860-3800
Practice Address - Street 1:AVE PRINCIPAL F4
Practice Address - Street 2:URB BARALT
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-860-3700
Practice Address - Fax:787-860-3800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization