Provider Demographics
NPI:1265874689
Name:GRUPO FISIATRICO-DENTAL DEL ESTE, CORP.
Entity type:Organization
Organization Name:GRUPO FISIATRICO-DENTAL DEL ESTE, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-887-1110
Mailing Address - Street 1:SAN FRANCISCO
Mailing Address - Street 2:225 CALLE VIOLETA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-6223
Mailing Address - Country:US
Mailing Address - Phone:787-887-1110
Mailing Address - Fax:787-888-7008
Practice Address - Street 1:JARDINES DE RIO GRANDE
Practice Address - Street 2:CALLE 54 BG-176
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-887-1110
Practice Address - Fax:787-888-7008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1780122300000X
PR10386208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG41668Medicare UPIN