Provider Demographics
NPI:1619958634
Name:CENTRO OTOLOGICO DE PUERTO RICO CSP
Entity Type:Organization
Organization Name:CENTRO OTOLOGICO DE PUERTO RICO CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LASALLE LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-833-2155
Mailing Address - Street 1:PO BOX 6428
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-6428
Mailing Address - Country:US
Mailing Address - Phone:787-833-2155
Mailing Address - Fax:787-833-2680
Practice Address - Street 1:55 CALLE DE DIEGO E
Practice Address - Street 2:SUITE 105
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-5078
Practice Address - Country:US
Practice Address - Phone:787-833-2155
Practice Address - Fax:787-833-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11064207YX0901X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20192OtherTRIPLES
20192OtherTRIPLES