Provider Demographics
NPI:1689067027
Name:INSTITUTO DE NEUROLOGIA DRA. IVONNE FRAGA, PSC
Entity Type:Organization
Organization Name:INSTITUTO DE NEUROLOGIA DRA. IVONNE FRAGA, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVONNE
Authorized Official - Middle Name:DE LOURDES
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-403-5534
Mailing Address - Street 1:PO BOX 7891
Mailing Address - Street 2:PMB 191
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-7891
Mailing Address - Country:US
Mailing Address - Phone:787-403-5534
Mailing Address - Fax:787-294-1246
Practice Address - Street 1:708 AVE PONCE DE LEON
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-4502
Practice Address - Country:US
Practice Address - Phone:787-763-9312
Practice Address - Fax:787-294-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13162261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH82111Medicare UPIN