Basic Information
| Provider Information | |||||||||
| NPI: | 1275533275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO VARGAS | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALDONADO VARGAS | ||||||||
| OtherFirstName: | JOSE | ||||||||
| OtherMiddleName: | ANTONIO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 AVE LA SIERRA | ||||||||
| Address2: | APT. 1 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009264330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875292964 | ||||||||
| FaxNumber: | 7877773855 | ||||||||
| Practice Location | |||||||||
| Address1: | ADMINISTRACION DE SERVICIOS MEDICOS DE PR | ||||||||
| Address2: | UPR-RADIOLOGIA, CARR. 22, BO. MONACILLOS | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773535 | ||||||||
| FaxNumber: | 7877773855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2005 | ||||||||
| LastUpdateDate: | 09/02/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 14572 | PR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 14572 | 01 | PR | PUERTO RICO MEDICINE ID | OTHER |