Provider Demographics
NPI:1740257856
Name:BORRERO DE JESUS, SAMUEL (MD)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:BORRERO DE JESUS
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 310
Mailing Address - Street 2:
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757-0310
Mailing Address - Country:US
Mailing Address - Phone:787-594-8871
Mailing Address - Fax:787-845-8871
Practice Address - Street 1:909 PLAZA OASIS, CARR. 153
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757
Practice Address - Country:US
Practice Address - Phone:787-845-4466
Practice Address - Fax:787-845-8871
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12016207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0089006Medicare ID - Type UnspecifiedPROVIDER NUMBER
PRG46596Medicare UPIN