Provider Demographics
NPI:1659785632
Name:MONTALVAN MIRO DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MONTALVAN MIRO DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONTALVAN MIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-403-5401
Mailing Address - Street 1:1511 AVE PONCE DE LEON APT 1183
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-5001
Mailing Address - Country:US
Mailing Address - Phone:787-403-5401
Mailing Address - Fax:
Practice Address - Street 1:CARR 693 ESQUINA AVE. JOSE EFRON
Practice Address - Street 2:DOCTORS HEALTH CENTER DORADO CLINIC #24 PLAZA DORADA
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646-4810
Practice Address - Country:US
Practice Address - Phone:787-621-3322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center