Basic Information
| Provider Information | |||||||||
| NPI: | 1831505841 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN RETINA CONSULTANTS OF PUERTO RICO, PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | #15 AVE. PADRE RIVERA | ||||||||
| Address2: | |||||||||
| City: | HUMACAO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878526825 | ||||||||
| FaxNumber: | 7878505005 | ||||||||
| Practice Location | |||||||||
| Address1: | #15 AVE. PADRE RIVERA | ||||||||
| Address2: | |||||||||
| City: | HUMACAO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878526825 | ||||||||
| FaxNumber: | 7878505005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENITEZ BAJANDAS | ||||||||
| AuthorizedOfficialFirstName: | GABRIEL | ||||||||
| AuthorizedOfficialMiddleName: | ALBERTO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7876971171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 339876 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.