Provider Demographics
NPI:1649225806
Name:NEFROLOGIA INTERVENCIONAL CSP
Entity Type:Organization
Organization Name:NEFROLOGIA INTERVENCIONAL CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTO
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-805-7640
Mailing Address - Street 1:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3007
Mailing Address - Country:US
Mailing Address - Phone:787-805-7640
Mailing Address - Fax:787-805-7620
Practice Address - Street 1:351 AVE HOSTOS
Practice Address - Street 2:MEDICAL EMPORIUM SUITE 208
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1502
Practice Address - Country:US
Practice Address - Phone:787-805-7640
Practice Address - Fax:787-805-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12534207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F96617Medicare UPIN