Provider Demographics
NPI: | 1255495412 |
---|---|
Name: | CASAS DOLZ, INGRID LETICIA (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | INGRID |
Middle Name: | LETICIA |
Last Name: | CASAS DOLZ |
Suffix: | |
Gender: | F |
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: | 1400 N SEMORAN BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | ORLANDO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32807-3536 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 407-823-8421 |
Mailing Address - Fax: | 407-482-2389 |
Practice Address - Street 1: | CENTRO SALUD MENTAL, SAN JUAN BAUTISTA MEDICAL CENTER |
Practice Address - Street 2: | CALL BOX 4964 |
Practice Address - City: | CAGUAS |
Practice Address - State: | PR |
Practice Address - Zip Code: | 00726-4964 |
Practice Address - Country: | US |
Practice Address - Phone: | 787-653-0550 |
Practice Address - Fax: | 787-653-0525 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-12-21 |
Last Update Date: | 2017-11-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PR | 14873 | 2084P0800X, 2084P0804X |
FL | ACN945 | 2084P0804X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Single Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |