Provider Demographics
NPI:1790877199
Name:DISLA, TEMISTOCLES (MD)
Entity Type:Individual
Prefix:MR
First Name:TEMISTOCLES
Middle Name:
Last Name:DISLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 CALLE ALCALA
Mailing Address - Street 2:URB. COLLEGE PARK
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-4335
Mailing Address - Country:US
Mailing Address - Phone:787-616-7487
Mailing Address - Fax:787-753-3902
Practice Address - Street 1:1172 AVE DOS PALMAS
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:PR
Practice Address - Zip Code:00949-4102
Practice Address - Country:US
Practice Address - Phone:787-784-6396
Practice Address - Fax:787-753-3902
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5519207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5519OtherSTATE LICENSE
PR0026385Medicare ID - Type Unspecified
PR5519OtherSTATE LICENSE