Provider Demographics
NPI:1295293991
Name:GRUPO SAN MATEO, LLC
Entity type:Organization
Organization Name:GRUPO SAN MATEO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VASCO
Authorized Official - Middle Name:
Authorized Official - Last Name:EGUIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-633-5263
Mailing Address - Street 1:1353 AVE LUIS VIGOREAUX PMB 757
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2715
Mailing Address - Country:US
Mailing Address - Phone:787-633-5263
Mailing Address - Fax:888-588-0319
Practice Address - Street 1:1607 AVE PONCE DE LEON STE GM04
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-1803
Practice Address - Country:US
Practice Address - Phone:787-910-0909
Practice Address - Fax:888-588-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR037891301Medicaid