Provider Demographics
NPI:1326257197
Name:FIDALGO, MAGDA (MD)
Entity Type:Individual
Prefix:
First Name:MAGDA
Middle Name:
Last Name:FIDALGO
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:PMB 668 #138 AVE. WINSTON CHURCHILL
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-599-3192
Mailing Address - Fax:
Practice Address - Street 1:BO. MONACILLO CENTRO MEDICO
Practice Address - Street 2:HOSPITAL SAN JUAN
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00928
Practice Address - Country:US
Practice Address - Phone:787-765-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14970208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice