MEDICARE: DR. ELIZAMA MONTALVO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	164035	NY
2	207Q00000X	Family Medicine Physician	8834	PR

General Provider Information

NPI Number	:	1659465680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZAMA MONTALVO M.D.

Provider Business Mailing Address
First Line	:	HC 7 BOX 25877
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00731-9670
Country	:	US
Telephone Number	:	845-270-4234
Fax Number	:

Provider Business Practice Location Address
First Line	:	388 ZONA IND REPARADA 2
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00716-2347
Country	:	US
Telephone Number	:	787-840-1163
Fax Number	:	787-848-1306

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	03/18/2008

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