Provider Demographics
NPI:1538154315
Name:DAVILA-DEPEDRO, ROBERTO LUIS (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:LUIS
Last Name:DAVILA-DEPEDRO
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:PO BOX 191259
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-1259
Mailing Address - Country:US
Mailing Address - Phone:877-646-6117
Mailing Address - Fax:787-957-3110
Practice Address - Street 1:525 AVE ROOSVELET PLAZA LAS AMERICAS TOWER
Practice Address - Street 2:SUITE 712
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00918-8001
Practice Address - Country:US
Practice Address - Phone:787-764-6611
Practice Address - Fax:787-754-1596
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5154207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR27404OtherMEDICAL CARD SYSTEM