Provider Demographics
NPI:1457853483
Name:ACOSTA GARAYUA, PABLO OMAR
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:OMAR
Last Name:ACOSTA GARAYUA
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:HC 4 BOX 11946
Mailing Address - Street 2:
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-9608
Mailing Address - Country:US
Mailing Address - Phone:787-450-4980
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 365067
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936-5067
Practice Address - Country:US
Practice Address - Phone:787-758-2525
Practice Address - Fax:787-754-0710
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR32986-R207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR32986-ROtherMEDICAL LISCENCE