Provider Demographics
NPI:1811102502
Name:CDT DR MANUEL QUEVEDO BAEZ
Entity type:Organization
Organization Name:CDT DR MANUEL QUEVEDO BAEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LIC
Authorized Official - Phone:787-480-3901
Mailing Address - Street 1:PO BOX 21405
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-1405
Mailing Address - Country:US
Mailing Address - Phone:787-480-3901
Mailing Address - Fax:787-724-0696
Practice Address - Street 1:359 CALLE SAN AGUSTIN PUERTA DE TIERRA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-2908
Practice Address - Country:US
Practice Address - Phone:787-480-3901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========Medicaid
PR=========Medicaid