Provider Demographics
NPI:1689136079
Name:BURGOS HERNANDEZ, LUIS M (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:M
Last Name:BURGOS HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:312 CALLE PELLIN RODRIGUEZ
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00915-2235
Mailing Address - Country:US
Mailing Address - Phone:939-428-4560
Mailing Address - Fax:
Practice Address - Street 1:23 CALLE LAS MERCEDES
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783-2077
Practice Address - Country:US
Practice Address - Phone:787-859-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR544-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant