Provider Demographics
NPI:1932120698
Name:SMITH FERMOSO, EDWARD B (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:SMITH FERMOSO
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 1:130 AVE WINSTON CHURCHILL
Mailing Address - Street 2:SUITE 1 PMB 368
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6018
Mailing Address - Country:US
Mailing Address - Phone:787-761-6046
Mailing Address - Fax:
Practice Address - Street 1:AVE. GENERAL VALERO .KM.2.6 CARRE #194
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-655-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7830146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant