Basic Information
| Provider Information | |||||||||
| NPI: | 1619972635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMONETTI | ||||||||
| FirstName: | HUMBERTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P O BOX 7437 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PUERTO RICO | ||||||||
| PostalCode: | 007327437 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 17872597727 | ||||||||
| FaxNumber: | 17878414832 | ||||||||
| Practice Location | |||||||||
| Address1: | HOSPITAL SAN LUCAS II LOBBY | ||||||||
| Address2: | AVE TITO CASTRO CARR 14 BO MACHUELO | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | 7878414832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/17/2006 | ||||||||
| NPIReactivationDate: | 03/31/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 7884 | PR | N | Other Service Providers | Specialist | 207R00000X | 7884 | PR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.