Provider Demographics
NPI:1811023252
Name:CLINICA DE GASTROENTEROLOGIA
Entity Type:Organization
Organization Name:CLINICA DE GASTROENTEROLOGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:JANER-MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-779-6666
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-1132
Mailing Address - Country:US
Mailing Address - Phone:787-283-0804
Mailing Address - Fax:787-761-5764
Practice Address - Street 1:#73 SANTA CRUZ ST. STE 215
Practice Address - Street 2:SANTA CRUZ MEDICAL BUILDING
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6910
Practice Address - Country:US
Practice Address - Phone:787-283-0804
Practice Address - Fax:787-761-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13568207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020995Medicare PIN
PRH68175Medicare UPIN