Provider Demographics
NPI:1619123304
Name:BERRIOS, IDENISSE M (M D)
Entity Type:Individual
Prefix:
First Name:IDENISSE
Middle Name:M
Last Name:BERRIOS
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188-36 CALLE 516
Mailing Address - Street 2:VILLA CAROLINA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-3002
Mailing Address - Country:US
Mailing Address - Phone:787-757-8213
Mailing Address - Fax:
Practice Address - Street 1:188-36 CALLE 516
Practice Address - Street 2:VILLA CAROLINA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985-3002
Practice Address - Country:US
Practice Address - Phone:787-757-8213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR20387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine