Provider Demographics
NPI:1790902591
Name:COLON-QUETLAS, KERMIT (MD)
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:
Last Name:COLON-QUETLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KERMIT
Other - Middle Name:
Other - Last Name:COLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:URB PARK GARDENS N-43
Mailing Address - Street 2:CALLE ACADIA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-2123
Mailing Address - Country:US
Mailing Address - Phone:787-761-8755
Mailing Address - Fax:787-761-8755
Practice Address - Street 1:CALLE STA CRUZ NUM. 70
Practice Address - Street 2:URB SANTA CRUZ
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00960-0000
Practice Address - Country:US
Practice Address - Phone:787-620-4747
Practice Address - Fax:787-620-9409
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR27063OtherTRIPLE S