Provider Demographics
NPI:1639630270
Name:OTERO DE LEON, LIDIANNIE
Entity Type:Individual
Prefix:
First Name:LIDIANNIE
Middle Name:
Last Name:OTERO DE LEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 VILLAS DE MONTE VERDE
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736-9136
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:
Practice Address - Street 1:CARR 1 KM 50.2 BO BEATRIZ
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-0073
Practice Address - Country:US
Practice Address - Phone:787-455-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR23159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program