Provider Demographics
NPI:1659659654
Name:PONCE DE LEON MEDICAL DIAGNOSTIC
Entity Type:Organization
Organization Name:PONCE DE LEON MEDICAL DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-753-4648
Mailing Address - Street 1:456 TENIENTE CESAR GONZALEZ
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-0000
Mailing Address - Country:US
Mailing Address - Phone:787-753-4648
Mailing Address - Fax:
Practice Address - Street 1:CALLE BROMELIA 8 PARQUE DE BUCAREST
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-0000
Practice Address - Country:US
Practice Address - Phone:787-753-4648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory