Provider Demographics
NPI:1942435094
Name:PPL MEDICAL CSP
Entity Type:Organization
Organization Name:PPL MEDICAL CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINGO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-779-0484
Mailing Address - Street 1:100 GRAND BULEVARD PASEOS
Mailing Address - Street 2:SUITE 112 MSC 333
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5955
Mailing Address - Country:US
Mailing Address - Phone:787-779-0484
Mailing Address - Fax:787-779-3065
Practice Address - Street 1:68 SANTA CRUZ ST.
Practice Address - Street 2:SUITE 405
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7036
Practice Address - Country:US
Practice Address - Phone:787-779-0484
Practice Address - Fax:787-779-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9828101YM0800X
207RC0000X, 2084P0800X
PR9686261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1154343978OtherDOMINGO PEREZ
PR1306855275OtherLISA PRINCIPE