Provider Demographics
NPI:1679521645
Name:ESPARZA RAZO, BOGART R (MD)
Entity type:Individual
Prefix:
First Name:BOGART
Middle Name:R
Last Name:ESPARZA RAZO
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 76
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00715-0076
Mailing Address - Country:US
Mailing Address - Phone:787-284-0574
Mailing Address - Fax:787-284-0574
Practice Address - Street 1:URB VALLE VERDE PASEO REAL #1014
Practice Address - Street 2:STE 1
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-3500
Practice Address - Country:US
Practice Address - Phone:787-284-0574
Practice Address - Fax:787-284-0574
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR118492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87488Medicare UPIN
PR89951Medicare ID - Type Unspecified