Basic Information
Provider Information
NPI: 1548391733
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CEREZO
FirstName: EDUARDO
MiddleName:  
NamePrefix: MR.
NameSuffix: SR.
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: P.O. BOX 733
Address2:  
City: DORADO
State: PR
PostalCode: 00646
CountryCode: US
TelephoneNumber: 7878581580
FaxNumber: 7878788795
Practice Location
Address1: OFICINA 201, CARR #2
Address2: HOSPITAL WILMA VAZQUEZ
City: VEGA BAJA
State: PR
PostalCode: 00693
CountryCode: US
TelephoneNumber: 7878581580
FaxNumber: 7878788795
Other Information
ProviderEnumerationDate: 03/08/2007
LastUpdateDate: 01/05/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X4686PRY Other Service ProvidersSpecialist 

No ID Information.


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