Provider Demographics
NPI:1326109349
Name:SANTOS DEJESUS, IVONNE M
Entity Type:Individual
Prefix:DR
First Name:IVONNE
Middle Name:M
Last Name:SANTOS DEJESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SAN PATRICIO AVE
Mailing Address - Street 2:.SAN PATRICIO APARTMENTS # 1510
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968
Mailing Address - Country:US
Mailing Address - Phone:787-596-8383
Mailing Address - Fax:
Practice Address - Street 1:FARMACIA CARRAIZO
Practice Address - Street 2:CARR 844 KM. 5 HM 6
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00928
Practice Address - Country:US
Practice Address - Phone:787-760-2650
Practice Address - Fax:787-760-2650
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA#15614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA#15614OtherLOUISIANA STATE LICENCE #
PR004920OtherP.R. STATE LICENCE NUMBER