Provider Demographics
NPI:1174532535
Name:SAN PEDRO, ELMER C (MD)
Entity type:Individual
Prefix:
First Name:ELMER
Middle Name:C
Last Name:SAN PEDRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1645
Mailing Address - Country:US
Mailing Address - Phone:434-517-3403
Mailing Address - Fax:434-517-3686
Practice Address - Street 1:2204 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1645
Practice Address - Country:US
Practice Address - Phone:434-517-3187
Practice Address - Fax:434-517-3686
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012325332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology