Provider Demographics
NPI:1790843027
Name:PEDRAZA, IVEMILIA
Entity type:Individual
Prefix:
First Name:IVEMILIA
Middle Name:
Last Name:PEDRAZA
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:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:PATILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00723
Mailing Address - Country:US
Mailing Address - Phone:787-839-4320
Mailing Address - Fax:787-271-0004
Practice Address - Street 1:99 GUILLERMO RIEFKHOL ST.
Practice Address - Street 2:
Practice Address - City:PATILLAS
Practice Address - State:PR
Practice Address - Zip Code:00723
Practice Address - Country:US
Practice Address - Phone:787-839-4320
Practice Address - Fax:787-271-0004
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14463208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice