Provider Demographics
NPI:1053354720
Name:VIVALDI PICO, JOSE G (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:G
Last Name:VIVALDI PICO
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 1823
Mailing Address - Street 2:
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-8823
Mailing Address - Country:US
Mailing Address - Phone:787-262-8808
Mailing Address - Fax:787-262-8808
Practice Address - Street 1:CARR 130 KM 9.9
Practice Address - Street 2:BO CAMPO ALEGRE
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-8823
Practice Address - Country:US
Practice Address - Phone:787-262-8808
Practice Address - Fax:787-262-8808
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13164208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR90273Medicaid
PRH55620Medicare UPIN