Provider Demographics
NPI:1609241678
Name:DORADO MEDICAL COMPLEX LABORATORY
Entity Type:Organization
Organization Name:DORADO MEDICAL COMPLEX LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONGAY RULLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-278-1576
Mailing Address - Street 1:349 CALLE MENDEZ VIGO
Mailing Address - Street 2:SUITE 10
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-278-1576
Mailing Address - Fax:787-278-1576
Practice Address - Street 1:CALLE MENDEZ VIGO 349 SUITE 10
Practice Address - Street 2:
Practice Address - City:DORADO
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00646
Practice Address - Country:UM
Practice Address - Phone:787-278-1576
Practice Address - Fax:787-278-1576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1122291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR40D0992077OtherLIC 35