Provider Demographics
NPI:1962629154
Name:PONCE DE LEON ROSADO, IRMA
Entity Type:Individual
Prefix:MRS
First Name:IRMA
Middle Name:
Last Name:PONCE DE LEON ROSADO
Suffix:
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 1:42 MATTEI LLUBERAS
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698
Mailing Address - Country:US
Mailing Address - Phone:787-856-5272
Mailing Address - Fax:787-856-8421
Practice Address - Street 1:42 MATTEI LLUBERAS
Practice Address - Street 2:SUITE 1
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698
Practice Address - Country:US
Practice Address - Phone:787-856-5272
Practice Address - Fax:787-856-8421
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084104OtherREFORMA
PR84104Medicare ID - Type Unspecified