Provider Demographics
NPI:1053416404
Name:SERRA, EDGAR R (MD)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:R
Last Name:SERRA
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 1:25 AVE SEVERIANO CUEVAS
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-5713
Mailing Address - Country:US
Mailing Address - Phone:787-891-8090
Mailing Address - Fax:787-891-8190
Practice Address - Street 1:25 AVE SEVERIANO CUEVAS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5713
Practice Address - Country:US
Practice Address - Phone:787-891-8090
Practice Address - Fax:787-891-8190
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4943208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C79538Medicare UPIN
28309Medicare ID - Type Unspecified