Provider Demographics
NPI:1356302202
Name:IRIZARRY CEBALLOS, CARMEN D (MD)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:D
Last Name:IRIZARRY CEBALLOS
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:G14 VIA CUMBRES
Mailing Address - Street 2:LA VISTA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-4475
Mailing Address - Country:US
Mailing Address - Phone:787-750-8696
Mailing Address - Fax:787-750-8696
Practice Address - Street 1:CELIS AGUILERA 10B
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-801-6592
Practice Address - Fax:787-863-9080
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11188208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0083421Medicare ID - Type Unspecified
F94772Medicare UPIN