Provider Demographics
NPI:1386717247
Name:DOMENECH FAGUNDO, EDGAR E (MD)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:E
Last Name:DOMENECH FAGUNDO
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:PMB 137 PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715
Mailing Address - Country:US
Mailing Address - Phone:787-290-3333
Mailing Address - Fax:787-290-4444
Practice Address - Street 1:TORRE MEDICA SAN LUCAS, AVE. TITO CASTRO 917
Practice Address - Street 2:SUITE 618
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-290-3333
Practice Address - Fax:787-290-4444
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13247207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020400Medicare ID - Type Unspecified
PRG76827Medicare UPIN