Provider Demographics
NPI:1265663421
Name:ROMAN, CARLOS LUIS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:LUIS
Last Name:ROMAN
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:PO BOX 3691
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-3691
Mailing Address - Country:US
Mailing Address - Phone:787-381-5797
Mailing Address - Fax:787-790-3973
Practice Address - Street 1:PR-111
Practice Address - Street 2:KM. 13.8
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-280-6397
Practice Address - Fax:787-280-6397
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17651208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRCY917AOtherMEDICARE PTAN