Provider Demographics
NPI:1972587707
Name:SIACA COLON, LUIS M (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:M
Last Name:SIACA COLON
Suffix:
Gender:M
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:CHALETS DE BAIROA C/COLIBRI #96
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-1272
Mailing Address - Country:US
Mailing Address - Phone:787-308-3602
Mailing Address - Fax:787-736-8265
Practice Address - Street 1:DIAZ BRETANA MEDICAL BUILDING
Practice Address - Street 2:OFICINA 202
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754
Practice Address - Country:US
Practice Address - Phone:787-736-8265
Practice Address - Fax:787-736-8265
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR012479208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11912479OtherGLOBAL HEALTH
PRH55574Medicare UPIN
PR0089535Medicare ID - Type Unspecified