Provider Demographics
NPI:1922058932
Name:VICIOSO, MARGARITA III
Entity Type:Individual
Prefix:
First Name:MARGARITA
Middle Name:
Last Name:VICIOSO
Suffix:III
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:REXVILLE PLZ
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957-4160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EDIFICIO COBIAN PLAZA AVE. PONCE DE LEON
Practice Address - Street 2:PARADA 23 SUITE GM 4
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-273-1227
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI50000Medicare UPIN
PR0023193Medicare ID - Type Unspecified