Provider Demographics
NPI:1891729364
Name:DE JESUS, CARLOS I (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:I
Last Name:DE JESUS
Suffix:
Gender:M
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 7478
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7478
Mailing Address - Country:US
Mailing Address - Phone:787-448-1767
Mailing Address - Fax:
Practice Address - Street 1:1010 PASEO DEL VETERANO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2001
Practice Address - Country:US
Practice Address - Phone:787-812-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR105062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH-55609Medicare ID - Type Unspecified