Provider Demographics
NPI:1306247812
Name:CORONA RUIZ, MARIO AUGUSTO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:AUGUSTO
Last Name:CORONA RUIZ
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 1:105 AVE ARTERIAL HOSTOS
Mailing Address - Street 2:APT V201 OR APARTADO 216
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:939-645-6398
Mailing Address - Fax:
Practice Address - Street 1:2225 PONCE BYP STE 502
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1368
Practice Address - Country:US
Practice Address - Phone:787-934-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN69904207Y00000X
PR22921207YX0901X, 207Y00000X
PR4927717390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4937717OtherDRIVER LICENSE