Provider Demographics
NPI:1922136068
Name:CENTRO DE GASTROENTEROLOGIA
Entity Type:Organization
Organization Name:CENTRO DE GASTROENTEROLOGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS-CARABALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-283-0804
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-1132
Mailing Address - Country:US
Mailing Address - Phone:787-283-0804
Mailing Address - Fax:787-761-5764
Practice Address - Street 1:HOSPITAL EPISCOPAL CRISTO REDENTOR
Practice Address - Street 2:OFICINA DE GASTROENTEROLOGIA
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-283-0804
Practice Address - Fax:787-761-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14017207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0023958Medicare PIN
PRI51759Medicare UPIN
PR23958Medicare PIN