Provider Demographics
NPI:1699947457
Name:JORGE, MARILLIAM
Entity type:Individual
Prefix:
First Name:MARILLIAM
Middle Name:
Last Name:JORGE
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:RR 3 BOX 53030
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-9803
Mailing Address - Country:US
Mailing Address - Phone:787-412-3346
Mailing Address - Fax:787-797-6978
Practice Address - Street 1:CARRETERA 829 KM 1.8
Practice Address - Street 2:BARRIO PINA
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-412-3346
Practice Address - Fax:787-797-6978
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization