MEDICARE: MARTHA IVETT KYRIACOU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	21174	PR

General Provider Information

NPI Number	:	1437685831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA IVETT KYRIACOU M.D.

Provider Business Mailing Address
First Line	:	1511 AVE PONCE DE LEON
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00909-5001
Country	:	US
Telephone Number	:	787-339-2639
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 AVE PONCE DE LEON
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00909-5001
Country	:	US
Telephone Number	:	787-339-2639
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	10/23/2020

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