Provider Demographics
NPI:1487878542
Name:QUINTERO, MARIO LUIS (MD LAC)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:LUIS
Last Name:QUINTERO
Suffix:
Gender:M
Credentials:MD LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 1837
Mailing Address - Street 2:105 LUNA ST
Mailing Address - City:SAN GERMAIN
Mailing Address - State:PR
Mailing Address - Zip Code:00683
Mailing Address - Country:US
Mailing Address - Phone:787-892-4765
Mailing Address - Fax:
Practice Address - Street 1:105 LUNA ST
Practice Address - Street 2:
Practice Address - City:SAN GERMAIN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR077171100000X
PR07419208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
066886OtherB CROSS
28888Medicare ID - Type Unspecified