Basic Information
| Provider Information | |||||||||
| NPI: | 1093760522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANCHEZ DEL CAMPO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | EDSIQUIO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 LES JARDINS | ||||||||
| Address2: | |||||||||
| City: | TRUJILLO ALTO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009762212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877486614 | ||||||||
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| Practice Location | |||||||||
| Address1: | AVE. LUIS MUNOZ MARIN | ||||||||
| Address2: | URB. MARIOLGA | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876533434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 13241 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 9-02609A | 01 | PR | BLUE SHIELD PROVIDER | OTHER |