Provider Demographics
NPI:1902017551
Name:LEBRON, IVETTE (MD)
Entity Type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:LEBRON
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:PMB 112 PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-9607
Mailing Address - Country:US
Mailing Address - Phone:787-897-8787
Mailing Address - Fax:787-897-8787
Practice Address - Street 1:CARR 129 KM 23.5
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669-0000
Practice Address - Country:US
Practice Address - Phone:787-897-8787
Practice Address - Fax:787-897-8787
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16785208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16,785OtherMD LICENSE