Provider Demographics
NPI:1407453095
Name:DEJESUS, DAVID M
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:DEJESUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALLE NILO
Mailing Address - Street 2:UBR BRISAS DEL PRADO
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777-9400
Mailing Address - Country:US
Mailing Address - Phone:787-590-6988
Mailing Address - Fax:
Practice Address - Street 1:UBR PEREZ MORRIS
Practice Address - Street 2:500 CALLE BAEZ
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936-4189
Practice Address - Country:US
Practice Address - Phone:787-719-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR237861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0080028922292Medicaid