Healthcare Provider Details

I. General information

NPI: 1598459927
Provider Name (Legal Business Name): JEAN CARLOS MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CASIA
SAN JUAN PR
00921-3201
US

IV. Provider business mailing address

VCUHS GME ADMINISTRATION, BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-7582
  • Fax:
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0116041417
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: