Provider Demographics
NPI:1508869165
Name:MOURE-RODRIGUEZ, SERGIO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:RAFAEL
Last Name:MOURE-RODRIGUEZ
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:PO BOX 3866
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-3866
Mailing Address - Country:US
Mailing Address - Phone:787-787-7191
Mailing Address - Fax:787-786-3667
Practice Address - Street 1:EDIF INSTITUTO SAN PABLO
Practice Address - Street 2:SUITE 303
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7041
Practice Address - Country:US
Practice Address - Phone:787-787-7191
Practice Address - Fax:787-786-3667
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR066345OtherLA CRUZ AZUL DE PR
PR204040OtherPREFERRED HEALTH CARE
PR29466OtherTRIPLE S
PR33-08128OtherUIA
PR960010OtherHUMANA HEALTH CARE
PR0116OtherFIRST MEDICAL CARD SYSTEM
PRD32328Medicare UPIN
PR29466OtherTRIPLE S