Provider Demographics
NPI:1639997539
Name:SAN PEDRO MEDICAL GROUP
Entity type:Organization
Organization Name:SAN PEDRO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:LENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-346-7064
Mailing Address - Street 1:URB CIARA DEL SOL
Mailing Address - Street 2:CALLE CIARA DEL SUR # 35
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693
Mailing Address - Country:US
Mailing Address - Phone:787-346-7064
Mailing Address - Fax:
Practice Address - Street 1:URB CIARA DEL SOL
Practice Address - Street 2:CALLE CIARA DEL SUR # 35
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-346-7064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty