Provider Demographics
NPI:1760467922
Name:BURGOS, BOLIVAR
Entity Type:Individual
Prefix:DR
First Name:BOLIVAR
Middle Name:
Last Name:BURGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 313
Mailing Address - Street 2:110E FONT MARTELO ST.
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-0313
Mailing Address - Country:US
Mailing Address - Phone:787-852-5568
Mailing Address - Fax:787-852-5568
Practice Address - Street 1:110E AVE FONT MARTELO
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3928
Practice Address - Country:US
Practice Address - Phone:787-852-5568
Practice Address - Fax:787-852-5568
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR57302080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine