Healthcare Provider Details

I. General information

NPI: 1437157096
Provider Name (Legal Business Name): GARY GEORGE MONTALVO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE DOMENECH STE 506
SAN JUAN PR
00918-3710
US

IV. Provider business mailing address

400 AVE DOMENECH STE 506
SAN JUAN PR
00918-3710
US

V. Phone/Fax

Practice location:
  • Phone: 787-754-8625
  • Fax: 787-746-6650
Mailing address:
  • Phone: 787-754-8625
  • Fax: 787-746-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: