Provider Demographics
NPI:1487674248
Name:LLERAS, IDELISA (MD)
Entity Type:Individual
Prefix:MRS
First Name:IDELISA
Middle Name:
Last Name:LLERAS
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:LAS VIOLETAS ST. 2002
Mailing Address - Street 2:APT. 303
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00915
Mailing Address - Country:US
Mailing Address - Phone:787-450-4997
Mailing Address - Fax:787-748-3563
Practice Address - Street 1:TITO CASTROL AVE. #509
Practice Address - Street 2:MEDICAL X-RAY CENTER
Practice Address - City:PONEE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-840-5090
Practice Address - Fax:787-840-5090
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR44352085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC77616Medicare UPIN
C77616Medicare UPIN