Provider Demographics
NPI:1386903573
Name:MB DERMATOLOGY, PSC
Entity type:Organization
Organization Name:MB DERMATOLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BEAUCHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-630-1369
Mailing Address - Street 1:PMB 705, 89 DE DIEGO AVE.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-6320
Mailing Address - Country:US
Mailing Address - Phone:787-705-8887
Mailing Address - Fax:787-705-8886
Practice Address - Street 1:CENTRO INTERNACIONAL DE MERCADEO, TOWER 1, SUITE 304
Practice Address - Street 2:ROAD 165 PR-28
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968
Practice Address - Country:US
Practice Address - Phone:787-705-8887
Practice Address - Fax:787-705-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17621207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty