Provider Demographics
NPI:1245290956
Name:CEREZO DE LA ROSA, IVAN A (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:A
Last Name:CEREZO DE LA ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:AVE. PONCE DE LEON 804
Mailing Address - Street 2:SUITE 304 MIRAMAR
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:787-722-6746
Mailing Address - Fax:787-725-6207
Practice Address - Street 1:AVE. PONCE DE LEON 804
Practice Address - Street 2:SUITE 304 MIRAMAR
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-722-6746
Practice Address - Fax:787-725-6207
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9816208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRCC197AMedicare PIN
E81957Medicare UPIN