Provider Demographics
NPI:1225592082
Name:SERPA IRIZARRY, MIGUEL A
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:SERPA IRIZARRY
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 1:576 AVE ARTERIAL B
Mailing Address - Street 2:COLISEUM TOWER APT 2207
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-643-0397
Mailing Address - Fax:
Practice Address - Street 1:576 AVE ARTERIAL B
Practice Address - Street 2:COLISEUM TOWER APT 2207
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-643-0397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR36026208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice