Provider Demographics
NPI:1912989146
Name:AMEZAGA, ANGEL ROBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:ROBERTO
Last Name:AMEZAGA
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 362674
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-2674
Mailing Address - Country:US
Mailing Address - Phone:787-752-6355
Mailing Address - Fax:787-769-2180
Practice Address - Street 1:3FS 11 AVE. FRAGOSO
Practice Address - Street 2:VILLA FONTANA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983
Practice Address - Country:US
Practice Address - Phone:787-752-6355
Practice Address - Fax:787-769-2180
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6416207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
29273Medicare ID - Type Unspecified
D08502Medicare UPIN