Provider Demographics
NPI:1023515194
Name:VARELA DELIZ, EDIEL J
Entity type:Individual
Prefix:
First Name:EDIEL
Middle Name:J
Last Name:VARELA DELIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 AVE MUNOZ RIVERA
Mailing Address - Street 2:COND AQUABLUE APT 2106
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-602-0322
Mailing Address - Fax:
Practice Address - Street 1:SANTURCE MEDICAL MALL
Practice Address - Street 2:1801 AVE PONCE DE LEON SUITE 309
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-728-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14620-I390200000X
PR21147208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR021147Medicaid
PR021147OtherMEDICAL DOCTOR