Provider Demographics
NPI:1811238496
Name:BURGOS, JESUS MANUEL
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:MANUEL
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 3162
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-3162
Mailing Address - Country:US
Mailing Address - Phone:787-597-6472
Mailing Address - Fax:787-846-2334
Practice Address - Street 1:1750 CARR S STE1
Practice Address - Street 2:
Practice Address - City:BARCELONETA
Practice Address - State:PR
Practice Address - Zip Code:00617-3355
Practice Address - Country:US
Practice Address - Phone:787-846-4583
Practice Address - Fax:787-846-2334
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004895183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician