Basic Information
| Provider Information | |||||||||
| NPI: | 1477668754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALAVE | ||||||||
| FirstName: | MARISOL | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PARQ DEL SOL APT 329 | ||||||||
| Address2: | |||||||||
| City: | BAYAMON | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009594304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877260210 | ||||||||
| FaxNumber: | 7877285136 | ||||||||
| Practice Location | |||||||||
| Address1: | CALLE SAN JORGE #252 SAN JORGE MEDIICAL OFFICE | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877260210 | ||||||||
| FaxNumber: | 7877285136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 13,673 | PR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8-9351 | 01 | PR | SSS | OTHER |