Provider Demographics
NPI:1215313986
Name:BURGOS ORTEGA, NYDIA IVETTE
Entity type:Individual
Prefix:
First Name:NYDIA
Middle Name:IVETTE
Last Name:BURGOS ORTEGA
Suffix:
Gender:F
Credentials:
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 192082
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-2082
Mailing Address - Country:US
Mailing Address - Phone:787-221-7540
Mailing Address - Fax:
Practice Address - Street 1:101 AVE SAN PATRICIO STE 1070
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-3048
Practice Address - Country:US
Practice Address - Phone:787-221-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR019944207R00000X
390200000X
PR19944207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program