Provider Demographics
NPI:1194304014
Name:POU ACEVEDO, EDGAR ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:ALLAN
Last Name:POU ACEVEDO
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AVE. SEVERIANO CUEVAS #18 KM 141.1 BO. CAIMITAL BAJO
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-658-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR023556208D00000X
PR1617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant