Provider Demographics
NPI:1356325930
Name:CENTRO MEDICO SAN JOSE CSP
Entity Type:Organization
Organization Name:CENTRO MEDICO SAN JOSE CSP
Other - Org Name:CLINICA SAN JOSE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:IGUINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-785-5592
Mailing Address - Street 1:C/A IHAMBRD 4 #8 URB TORRIMAR
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-785-5592
Mailing Address - Fax:787-785-5593
Practice Address - Street 1:CALLE MARGINAL
Practice Address - Street 2:URB SANTA CRUZ
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00957-2536
Practice Address - Country:US
Practice Address - Phone:787-785-5592
Practice Address - Fax:787-785-5593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10574208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty