Provider Demographics
NPI:1730439886
Name:DR. JACA MONTIJO CSP
Entity type:Organization
Organization Name:DR. JACA MONTIJO CSP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:JACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-559-5212
Mailing Address - Street 1:1995 CARR 2 STE 2903
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959-5062
Mailing Address - Country:US
Mailing Address - Phone:787-395-7500
Mailing Address - Fax:787-395-7501
Practice Address - Street 1:METROMEDICAL
Practice Address - Street 2:SUITE 903
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-5065
Practice Address - Country:US
Practice Address - Phone:787-935-7500
Practice Address - Fax:787-395-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13094207RG0100X, 261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHY226AMedicaid