Basic Information
| Provider Information | |||||||||
| NPI: | 1649727405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUIZ BOADA | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1506 AVE ASHFORD APT 602 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009111168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872929994 | ||||||||
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| Practice Location | |||||||||
| Address1: | HOSPITAL PEDIATRICO UNIVERSITARIO DR ANTONIO ORTIZ | ||||||||
| Address2: | CARRETERA 22 BARRIO MONACILLOS, CENTRO MEDICO | ||||||||
| City: | RIO PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874740333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2016 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 21409 | PR | Y | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 21409 | 01 | PR | STATE MEDICAL LICENSE OF PUERTO RICO | OTHER |