Provider Demographics
NPI:1407050776
Name:MEDIAVILLA, CARMEN LUISA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:LUISA
Last Name:MEDIAVILLA
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 1:400 AVE. F.D. ROOSEVELT
Mailing Address - Street 2:,CLINICA LAS AMERICAS SUITE 203
Mailing Address - City:HATO REY
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-783-4423
Mailing Address - Fax:787-781-5342
Practice Address - Street 1:400 AVE. F.D. ROOSEVELT
Practice Address - Street 2:,CLINICA LAS AMERICAS SUITE 203
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-783-4423
Practice Address - Fax:787-781-5342
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004984261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR004984OtherLICENSE MD,PR
PR98980OtherPROVIDER #TRIPLE-S MANAGE