Basic Information
Provider Information | |||||||||
NPI: | 1588858054 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALDONADO | ||||||||
FirstName: | MIRCA | ||||||||
MiddleName: | NOEMI | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | TO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | URB. LAS LOMAS | ||||||||
Address2: | CALLE 20 SO 1664 | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 00921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877773535 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | HOSP. PEDIATRICO UNIVERSITARIO, CENTRO PEDIATRICO METRO | ||||||||
Address2: | # 191079 | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009191079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877773535 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2007 | ||||||||
LastUpdateDate: | 08/28/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 000746 | PR | Y |   | Other Service Providers | Specialist |   |
No ID Information.