Provider Demographics
NPI:1669680054
Name:ASOMANTE MEDICAL GROUP
Entity Type:Organization
Organization Name:ASOMANTE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-717-5655
Mailing Address - Street 1:26 CALLE LEPANTO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-1905
Mailing Address - Country:US
Mailing Address - Phone:787-991-1790
Mailing Address - Fax:
Practice Address - Street 1:CARR 723 KM. 0.1
Practice Address - Street 2:BO. ASOMANTE
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-991-1790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR84752Medicare ID - Type UnspecifiedPROVIDER #