Healthcare Provider Details

I. General information

NPI: 1477732931
Provider Name (Legal Business Name): ELISEO MARTINEZ - GONZALEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CANDINA APT 7-A
SAN JUAN PR
00907-1404
US

IV. Provider business mailing address

PO BOX 366008
SAN JUAN PR
00936-6008
US

V. Phone/Fax

Practice location:
  • Phone: 787-722-0386
  • Fax:
Mailing address:
  • Phone: 787-722-0386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number593
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: