Provider Demographics
NPI:1710031661
Name:BURGOS, IDALIA (LND)
Entity Type:Individual
Prefix:MRS
First Name:IDALIA
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:B40 CALLE 2
Mailing Address - Street 2:URB.PASEO LAS VISTAS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5951
Mailing Address - Country:US
Mailing Address - Phone:787-376-4116
Mailing Address - Fax:
Practice Address - Street 1:1017 CALLE GEN DEL VALLE
Practice Address - Street 2:URB LAS DELICIAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3722
Practice Address - Country:US
Practice Address - Phone:787-376-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR114133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3264OtherAMERICAN HEALTH
PRNUT 005OtherPHP
PR9240091OtherHUMANA HEALTH PLAN
PR50338OtherPMC
PRNUT 005OtherPHP