Provider Demographics
NPI:1831576826
Name:MALDONADO, ANGEL LUIS (MA)
Entity type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:LUIS
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 3146
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669
Mailing Address - Country:US
Mailing Address - Phone:787-245-3430
Mailing Address - Fax:
Practice Address - Street 1:HC 1 BOX 3146
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669-9603
Practice Address - Country:US
Practice Address - Phone:787-245-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRJEPPR#5480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20150424Medicaid