Provider Demographics
NPI:1609896281
Name:ALICEA, IDAMARIS (MD)
Entity Type:Individual
Prefix:
First Name:IDAMARIS
Middle Name:
Last Name:ALICEA
Suffix:
Gender:F
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 211
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-0211
Mailing Address - Country:US
Mailing Address - Phone:787-897-6802
Mailing Address - Fax:
Practice Address - Street 1:CARR. 111 KM 22.2
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-897-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16087208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice