Provider Demographics
NPI:1306035928
Name:BERETTA, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERETTA
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:EXTENSION SAN AGUSTIN # B-11 CALLE 10
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-1900
Mailing Address - Country:US
Mailing Address - Phone:787-478-2050
Mailing Address - Fax:787-764-7796
Practice Address - Street 1:EXTENSION SAN AGUSTIN # B-11 CALLE 10
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-1900
Practice Address - Country:US
Practice Address - Phone:787-646-0840
Practice Address - Fax:787-764-7796
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC AMB 4823416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0058872Medicare PIN