Provider Demographics
NPI:1720091218
Name:MONTIJO COLON, JORGE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:A
Last Name:MONTIJO COLON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 AVE PONCE DE LEON
Mailing Address - Street 2:1106
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-4831
Mailing Address - Country:US
Mailing Address - Phone:787-763-2660
Mailing Address - Fax:787-763-2660
Practice Address - Street 1:623 AVE PONCE DE LEON
Practice Address - Street 2:1106
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-4831
Practice Address - Country:US
Practice Address - Phone:787-763-2660
Practice Address - Fax:787-763-2660
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR211103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRR62335Medicare UPIN
PR8-4172Medicare ID - Type Unspecified