Healthcare Provider Details

I. General information

NPI: 1104716422
Provider Name (Legal Business Name): PEDRO LUIS AGOSTO MARTINEZ MS, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 06/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. EL ENCANTO 111 CALLE AZAHAR
JUNCOS PR
00777-7719
US

IV. Provider business mailing address

URB. EL ENCANTO 111 CALLE AZAHAR
JUNCOS PR
00777-7719
US

V. Phone/Fax

Practice location:
  • Phone: 787-907-2798
  • Fax:
Mailing address:
  • Phone: 787-907-2798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number008334
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: