Healthcare Provider Details

I. General information

NPI: 1124650973
Provider Name (Legal Business Name): GIANCARLO MARTINEZ TELLADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA LUIS MUNOZ RIVERA #63
CAMUY PR
00627
US

IV. Provider business mailing address

PO BOX 660
CAMUY PR
00627-0660
US

V. Phone/Fax

Practice location:
  • Phone: 787-898-2660
  • Fax:
Mailing address:
  • Phone: 787-898-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number24052
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: