Provider Demographics
NPI:1174261572
Name:LLAURADOR, IAN MARK
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MARK
Last Name:LLAURADOR
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:FM4 CALLE JOSE PH HERNANDEZ
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-2817
Mailing Address - Country:US
Mailing Address - Phone:787-510-7701
Mailing Address - Fax:
Practice Address - Street 1:CALLE SERGIO CUEVAS BUSTAMANTE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927
Practice Address - Country:US
Practice Address - Phone:787-758-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program