Provider Demographics
NPI:1629031331
Name:CONDADO OTOLARYNGOLOGY PSC
Entity Type:Organization
Organization Name:CONDADO OTOLARYNGOLOGY PSC
Other - Org Name:JOSE R. DE LEON JIMENEZ
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DE LEON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:787-776-1511
Mailing Address - Street 1:1357 AVENIDA ASHFORD
Mailing Address - Street 2:PBM 428
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:787-785-8981
Mailing Address - Fax:787-780-4866
Practice Address - Street 1:PLAZA LAS AMERICAS
Practice Address - Street 2:TORRE DE PLAZA SUITE 907
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-281-1200
Practice Address - Fax:787-776-1531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12876207Y00000X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0085241Medicare PIN
PRH31020Medicare UPIN