Provider Demographics
NPI:1407813181
Name:DE DIEGO AMBULATORY CLINIC CORP
Entity Type:Organization
Organization Name:DE DIEGO AMBULATORY CLINIC CORP
Other - Org Name:ASC SAN JUAN MEDICAL PLAZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-977-7575
Mailing Address - Street 1:150 AVE DE DIEGO
Mailing Address - Street 2:CONDOMINIO SAN JUAN HEALTH CENTRE BOX 1
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-2300
Mailing Address - Country:US
Mailing Address - Phone:787-977-7575
Mailing Address - Fax:787-977-7605
Practice Address - Street 1:150 AVE DE DIEGO
Practice Address - Street 2:CONDOMINIO SAN JUAN HEALTH CENTRE BOX 1
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-2300
Practice Address - Country:US
Practice Address - Phone:787-977-7575
Practice Address - Fax:787-977-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR30261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0018031Medicare PIN