Provider Demographics
NPI:1104910793
Name:JOG OTOLARYNGOLOGY SERVICES CSP
Entity type:Organization
Organization Name:JOG OTOLARYNGOLOGY SERVICES CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:E
Authorized Official - Last Name:OTERO GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-725-5628
Mailing Address - Street 1:29 WASHINGTON SUITE 105
Mailing Address - Street 2:ASHFORD MEDICAL CENTER
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:787-725-5628
Mailing Address - Fax:787-722-0513
Practice Address - Street 1:29 WASHINGTON SUITE 105
Practice Address - Street 2:ASHFORD MEDICAL CENTER
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-725-5628
Practice Address - Fax:787-722-0513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12317207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH75005Medicare UPIN
PR0021076Medicare ID - Type Unspecified