Provider Demographics
NPI:1972712040
Name:ALMODOVAR, EDGAR R (MA)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:R
Last Name:ALMODOVAR
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:EDGAR
Other - Middle Name:R
Other - Last Name:ALMODOVAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:PMB 366, WINSTON CHURCHILL AVE.138
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6013
Mailing Address - Country:US
Mailing Address - Phone:787-758-8787
Mailing Address - Fax:
Practice Address - Street 1:PMB 366, WINSTON CHURCHILL AVE.138
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6013
Practice Address - Country:US
Practice Address - Phone:787-758-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR231103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical