Provider Demographics
NPI:1790750529
Name:CDT GMSP, INC
Entity Type:Organization
Organization Name:CDT GMSP, INC
Other - Org Name:LAB CDT GMSP
Other - Org Type:Other Name
Authorized Official - Title/Position:EXUCUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ILIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ZAYAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-780-9196
Mailing Address - Street 1:B7 CALLE SANTA CRUZ
Mailing Address - Street 2:AVE. SANTA CRUZ
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-6902
Mailing Address - Country:US
Mailing Address - Phone:787-780-9196
Mailing Address - Fax:787-625-6120
Practice Address - Street 1:B7 CALLE SANTA CRUZ
Practice Address - Street 2:AVE. SANTA CRUZ
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6902
Practice Address - Country:US
Practice Address - Phone:787-780-9196
Practice Address - Fax:787-625-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1028291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1790750529OtherNPI
PR0039200OtherMEDICARE PROVIDER
PR037546800Medicaid
PR40D0699278OtherCLIA NUMBER