Basic Information
| Provider Information | |||||||||
| NPI: | 1245231497 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GASTRO MED DEL SUR, P.S.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 909 AVE. TITO CASTRO SUITE 518 | ||||||||
| Address2: | TORRE MEDICA SAN LUCAS | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007164721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872902948 | ||||||||
| FaxNumber: | 7878414832 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 AVE. TITO CASTRO SUITE 518 | ||||||||
| Address2: | TORRE MEDICA SAN LUCAS | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007164721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872902948 | ||||||||
| FaxNumber: | 7878414832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 12/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANTIAGO | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7872902948 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 8042 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.