Provider Demographics
NPI:1255520482
Name:CENTRO MEDICO IBEROAMERICANO INC.
Entity type:Organization
Organization Name:CENTRO MEDICO IBEROAMERICANO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-684-8138
Mailing Address - Street 1:416 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-1930
Mailing Address - Country:US
Mailing Address - Phone:973-684-8138
Mailing Address - Fax:973-684-0032
Practice Address - Street 1:416 PARK AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-1930
Practice Address - Country:US
Practice Address - Phone:973-684-8138
Practice Address - Fax:973-684-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1055488OtherHORIZON NJ HEALTH
NJ6051308Medicaid
F73229OtherUPIN
748182Medicare PIN