Provider Demographics
NPI:1356421549
Name:BIDOT PREVENTIVE MEDICINE CSP
Entity type:Organization
Organization Name:BIDOT PREVENTIVE MEDICINE CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BIDOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-265-4610
Mailing Address - Street 1:67 CALLE EDUARDO RIERA
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-3811
Mailing Address - Country:US
Mailing Address - Phone:787-265-4610
Mailing Address - Fax:
Practice Address - Street 1:67 CALLE EDUARDO RIERA
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-3811
Practice Address - Country:US
Practice Address - Phone:787-265-4610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9542261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR9542OtherSTATE LICENCE
PR8-1944Medicare ID - Type UnspecifiedMEDICARE
PRE63416Medicare UPIN