Provider Demographics
NPI:1861497869
Name:BERDECIA, SANDRA T (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:T
Last Name:BERDECIA
Suffix:
Gender:F
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:PO BOX 194882
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-4882
Mailing Address - Country:US
Mailing Address - Phone:787-753-3024
Mailing Address - Fax:787-753-3026
Practice Address - Street 1:112 CALLE ARZUAGA
Practice Address - Street 2:OFICINA 902
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00925-3321
Practice Address - Country:US
Practice Address - Phone:787-753-3024
Practice Address - Fax:787-753-3026
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12679174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12679OtherSTATE LICENSE
PRH45540Medicare UPIN
PR12679OtherSTATE LICENSE