Provider Demographics
NPI:1063585024
Name:MUBARAK PERDOMO, MARISOL M (MD)
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:M
Last Name:MUBARAK PERDOMO
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:CALLE BIENTEVEO NUM 94
Mailing Address - Street 2:MONTEHIEDRA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-724-8945
Mailing Address - Fax:
Practice Address - Street 1:1451 AVE ASHFORD ESQ NAIRM
Practice Address - Street 2:ESTACIONAMIENTO LA GALERIA SUITE 611
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1567
Practice Address - Country:US
Practice Address - Phone:787-724-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR111772084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR217023OtherPREFERRED HEALTH
PR0500133OtherHUMANA HEALTH PLANS
PR600108OtherMEDICARE Y MUCHO MAS
PR83360OtherTRIPLE S
PR0500133OtherHUMANA HEALTH PLANS
PRF59459Medicare UPIN