Healthcare Provider Details

I. General information

NPI: 1790789485
Provider Name (Legal Business Name): MANUEL ANTONIO MARTINEZ-GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431 LAS AMERICAS AVE. SUITE 308
PONCE PR
00717-2116
US

IV. Provider business mailing address

2431 LAS AMERICAS AVE. SUITE 308
PONCE PR
00717-2116
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-9442
  • Fax: 787-844-9444
Mailing address:
  • Phone: 787-844-9442
  • Fax: 787-844-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number11766
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: