Provider Demographics
NPI:1538138789
Name:JUSINO, EDMUNDO SR (MD)
Entity Type:Individual
Prefix:MR
First Name:EDMUNDO
Middle Name:
Last Name:JUSINO
Suffix:SR
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 1147
Mailing Address - Street 2:
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698
Mailing Address - Country:US
Mailing Address - Phone:787-267-6017
Mailing Address - Fax:787-267-6017
Practice Address - Street 1:BALDORIOTY 18-4
Practice Address - Street 2:
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698
Practice Address - Country:US
Practice Address - Phone:787-267-6017
Practice Address - Fax:787-267-6017
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6812208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8913OtherIMC
2979OtherPMC
200006OtherMMM
PR7680045OtherHUMANA
PR2979OtherPMC
PR5062OtherAHMPR
PR2979OtherPMC
PR8913OtherIMC