Provider Demographics
NPI:1669441986
Name:DE JESUS ROMAN, TOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:TOMAS
Middle Name:
Last Name:DE JESUS ROMAN
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 1:2225 PONCE BY PASS
Mailing Address - Street 2:PARRA MEDICAL INSTITUTE SUITE 906
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1321
Mailing Address - Country:US
Mailing Address - Phone:787-284-2308
Mailing Address - Fax:787-844-3636
Practice Address - Street 1:2225 PONCE BY PASS
Practice Address - Street 2:PARRA MEDICAL INSTITUTE SUITE 906
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1321
Practice Address - Country:US
Practice Address - Phone:787-284-2308
Practice Address - Fax:787-844-3636
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4451174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR96966Medicare ID - Type Unspecified
PREO4099Medicare UPIN