Provider Demographics
NPI:1669015319
Name:ROSA BENIQUE, LUIS IVAN (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:IVAN
Last Name:ROSA BENIQUE
Suffix:
Gender:M
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:HC- 56 BOX 46772
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602
Mailing Address - Country:US
Mailing Address - Phone:939-288-8145
Mailing Address - Fax:
Practice Address - Street 1:BO NARANJO CARR 417 R 4415 KM 3.6
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602
Practice Address - Country:US
Practice Address - Phone:939-288-8145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22852208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice