Provider Demographics
NPI:1194715573
Name:PETERSON-CAMACHO, ANIBAL (MD)
Entity type:Individual
Prefix:
First Name:ANIBAL
Middle Name:
Last Name:PETERSON-CAMACHO
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:CALLE 15 H 13
Mailing Address - Street 2:JAIDINES DE CAPARRA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CMS DR E KOPPISCH
Practice Address - Street 2:BARBASA ESQ SICILIA 404
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:487-758-8840
Practice Address - Fax:787-758-9962
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6570208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG86385Medicare UPIN