Provider Demographics
NPI:1336131549
Name:FEBLES-GORDIAN, INDRA (MD)
Entity Type:Individual
Prefix:
First Name:INDRA
Middle Name:
Last Name:FEBLES-GORDIAN
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:COND.PLAZA REALCAPARRA
Mailing Address - Street 2:#187 CARR# 2 APT#202
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-1816
Mailing Address - Country:US
Mailing Address - Phone:787-439-9095
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR110472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1114OtherREFORMA PUBLIC HEALTH INS
1929OtherMMM #
2191OtherHUMANA
065526OtherCRUZ AZUL
3655OtherIMC INTL MEDICAL CARD
040216OtherFHC OPTIONS
3655OtherIMC INTL MEDICAL CARD
040216OtherFHC OPTIONS