Provider Demographics
NPI:1952473480
Name:CARDONA CAMPOS, IVAN RENE (MD)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:RENE
Last Name:CARDONA CAMPOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RENE
Other - Middle Name:
Other - Last Name:CARDONA CAMPOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19780
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910-9780
Mailing Address - Country:US
Mailing Address - Phone:787-723-5553
Mailing Address - Fax:787-723-4403
Practice Address - Street 1:1409 FERIA STREET
Practice Address - Street 2:
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-723-4403
Practice Address - Fax:787-723-4403
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3032207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2453OtherPMC
PR600024OtherMMM
PRH264OtherFIRST MEDICAL
PR2453OtherPMC
PRH264OtherFIRST MEDICAL