Provider Demographics
NPI:1407238900
Name:CONDE SAN MIGUEL, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:CONDE SAN MIGUEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 PONCE BYPASS SUITE 407
Mailing Address - Street 2:HOSPITAL DAMAS
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1318
Mailing Address - Country:US
Mailing Address - Phone:787-840-8686
Mailing Address - Fax:
Practice Address - Street 1:2225 PONCE BYPASS SUITE 407
Practice Address - Street 2:HOSPITAL DAMAS
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1318
Practice Address - Country:US
Practice Address - Phone:787-840-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31,659-R390200000X
TN58887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program