Provider Demographics
NPI:1104035922
Name:DELVALLE, MAYRA LISSETTE (MD)
Entity Type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:LISSETTE
Last Name:DELVALLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4968
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-4968
Mailing Address - Country:US
Mailing Address - Phone:787-235-7364
Mailing Address - Fax:
Practice Address - Street 1:901 AVE EMERITO ESTRADA
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685-3000
Practice Address - Country:US
Practice Address - Phone:787-280-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12169208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH31636Medicare UPIN
PR0088093Medicare ID - Type Unspecified