Provider Demographics
NPI:1578607776
Name:CEREZO, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:CEREZO
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 1:772 CALLE MAR NEGRO
Mailing Address - Street 2:LOS CORALES II
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-4546
Mailing Address - Country:US
Mailing Address - Phone:787-855-8045
Mailing Address - Fax:
Practice Address - Street 1:52 CALLE PALMER
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-2428
Practice Address - Country:US
Practice Address - Phone:787-870-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16645207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease