Provider Demographics
NPI:1639186547
Name:DEJESUS, MYRNA ENITH (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:ENITH
Last Name:DEJESUS
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 304
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-0304
Mailing Address - Country:US
Mailing Address - Phone:787-746-4610
Mailing Address - Fax:787-745-4030
Practice Address - Street 1:X2 AVE MUNOZ MARIN
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-6431
Practice Address - Country:US
Practice Address - Phone:787-746-4610
Practice Address - Fax:787-745-4030
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8868208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8868OtherPR LICENSE
PR84312Medicare ID - Type Unspecified
PR8868OtherPR LICENSE