Provider Demographics
NPI:1255469003
Name:CENTRO MEDICINA FAMILIA GERIATRIA DR. LUIS IZQUIERDO MORA
Entity Type:Organization
Organization Name:CENTRO MEDICINA FAMILIA GERIATRIA DR. LUIS IZQUIERDO MORA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:M
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-764-8018
Mailing Address - Street 1:1107 CALLE WILLIAM JONES
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00925-3441
Mailing Address - Country:US
Mailing Address - Phone:787-764-8018
Mailing Address - Fax:787-763-5801
Practice Address - Street 1:1107 CALLE WILLIAM JONES
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-3441
Practice Address - Country:US
Practice Address - Phone:787-764-8018
Practice Address - Fax:787-763-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherMANAGED CARE ORGANIZATION