Healthcare Provider Details

I. General information

NPI: 1346654324
Provider Name (Legal Business Name): GARY G MONTALVO PETROVICH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE DOMENECH STE 506 LAS AMERICAS PROF CENTER
SAN JUAN PR
00918-0000
US

IV. Provider business mailing address

PO BOX 8465
CAGUAS PR
00726-8465
US

V. Phone/Fax

Practice location:
  • Phone: 787-754-8625
  • Fax: 787-754-8648
Mailing address:
  • Phone: 787-754-8625
  • Fax: 787-754-8648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5622
License Number StatePR

VIII. Authorized Official

Name: DR. GARY G MONTALVO
Title or Position: DUENO
Credential: M.D.
Phone: 787-754-8625