Provider Demographics
NPI:1275537763
Name:JUAN C. VELASCO CERVILLA MD CSP
Entity Type:Organization
Organization Name:JUAN C. VELASCO CERVILLA MD CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:VELASCO- CERVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-267-2811
Mailing Address - Street 1:PO BOX 3004
Mailing Address - Street 2:
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-3004
Mailing Address - Country:US
Mailing Address - Phone:787-267-2811
Mailing Address - Fax:787-267-1964
Practice Address - Street 1:40 - 25 DE JULIO
Practice Address - Street 2:
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698-0000
Practice Address - Country:US
Practice Address - Phone:787-267-2811
Practice Address - Fax:787-267-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10541207R00000X
PR15870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020493Medicare PIN