Provider Demographics
NPI:1275557563
Name:DE JESUS, MARIAN (MD)
Entity Type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:
Last Name:DE JESUS
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:EXT VILLAMAR
Mailing Address - Street 2:1025 CALLE MARGINAL VILLAMAR
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979-6348
Mailing Address - Country:US
Mailing Address - Phone:787-726-3901
Mailing Address - Fax:787-268-5838
Practice Address - Street 1:EXT VILLAMAR
Practice Address - Street 2:1025 CALLE MARGINAL VILLAMAR
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979-6348
Practice Address - Country:US
Practice Address - Phone:787-726-3901
Practice Address - Fax:787-268-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC79735Medicare UPIN