Provider Demographics
NPI:1881660678
Name:JUSTINIANO, JORGE L (M D)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:JUSTINIANO
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MENDEZ VIGO
Mailing Address - Street 2:109
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:787-833-0868
Mailing Address - Fax:787-833-0868
Practice Address - Street 1:CALLE MENDEZ VIGO 209 ESTE
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-833-0868
Practice Address - Fax:787-833-0868
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD95869Medicare UPIN