Provider Demographics
NPI:1679557474
Name:CORDOVA, ANA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:CORDOVA
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 1:400 BO TORTUGO
Mailing Address - Street 2:CORDOBA PARK BOX 17
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-9769
Mailing Address - Country:US
Mailing Address - Phone:787-728-1575
Mailing Address - Fax:787-726-0402
Practice Address - Street 1:252 CALLE SAN JORGE
Practice Address - Street 2:SUITE 504
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00912-3310
Practice Address - Country:US
Practice Address - Phone:787-728-1575
Practice Address - Fax:787-726-0402
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12902174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6605457455OtherMEDICAL CARD SYSTEM
20427OtherTRIPLE S, INC.