Basic Information
| Provider Information | |||||||||
| NPI: | 1336189950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLON-CANDELARIA | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | MILAGROS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 188 CALLE TEBAS | ||||||||
| Address2: | OLYMPIC COURT | ||||||||
| City: | LAS PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007719016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876417582 | ||||||||
| FaxNumber: | 7876414561 | ||||||||
| Practice Location | |||||||||
| Address1: | 188 CALLE TEBAS | ||||||||
| Address2: | OLYMPIC COURT | ||||||||
| City: | LAS PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007719016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876417582 | ||||||||
| FaxNumber: | 7876414561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 14102 | PR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 14102 | PR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 208M00000X | 14102 | PR | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7180119 | 01 | PR | HUMANA | OTHER | 100943 | 01 | PR | CRUZ AZUL DE PUERTO RICO | OTHER | 23321 CO | 01 | PR | TRIPLE-SSS | OTHER |