Provider Demographics
NPI:1942344916
Name:VEGUILLA-HERNANDEZ, ISAMARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ISAMARIE
Middle Name:
Last Name:VEGUILLA-HERNANDEZ
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:GT45 CALLE 207
Mailing Address - Street 2:3RA EXT. COUNTRY CLUB
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00982-2630
Mailing Address - Country:US
Mailing Address - Phone:787-316-2151
Mailing Address - Fax:787-655-9655
Practice Address - Street 1:AVE GENERAL VALERO
Practice Address - Street 2:#313-B
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3949
Practice Address - Country:US
Practice Address - Phone:787-655-9655
Practice Address - Fax:787-655-9655
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16539208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1-73377Medicare UPIN