Provider Demographics
NPI:1720203813
Name:MIRO CEBALLOS, JOSE ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:MIRO CEBALLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367056
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-7056
Mailing Address - Country:US
Mailing Address - Phone:787-749-0849
Mailing Address - Fax:787-749-9623
Practice Address - Street 1:1003 CALLE ACAPULCO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-4054
Practice Address - Country:US
Practice Address - Phone:787-749-0849
Practice Address - Fax:787-749-9623
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6979208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR29600MIOtherSSS PROVIDER NUMBER
PRC82653Medicare UPIN
PR29600MIOtherSSS PROVIDER NUMBER