Provider Demographics
NPI:1831780642
Name:CARDONA CARDONA, DENNIS OMAR
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:OMAR
Last Name:CARDONA CARDONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 12467
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-8264
Mailing Address - Country:US
Mailing Address - Phone:939-253-8039
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 KM 141.1 AVENIDA SEVERIANO CUEVAS
Practice Address - Street 2:18 CAIMITAL BAJO
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-0880
Practice Address - Country:US
Practice Address - Phone:939-253-8039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2022-09-14
Deactivation Date:2022-08-14
Deactivation Code:
Reactivation Date:2022-09-12
Provider Licenses
StateLicense IDTaxonomies
PR15710-I390200000X
PR22929208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program