Provider Demographics
NPI:1548391733
Name:CEREZO, EDUARDO SR (MD)
Entity Type:Individual
Prefix:MR
First Name:EDUARDO
Middle Name:
Last Name:CEREZO
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:P.O. BOX 733
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-858-1580
Mailing Address - Fax:787-878-8795
Practice Address - Street 1:OFICINA 201, CARR #2
Practice Address - Street 2:HOSPITAL WILMA VAZQUEZ
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-858-1580
Practice Address - Fax:787-878-8795
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0025552Medicare UPIN