Provider Demographics
NPI:1205813821
Name:IRIZARRY, ELMER LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELMER
Middle Name:LUIS
Last Name:IRIZARRY
Suffix:
Gender:M
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 7245
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7245
Mailing Address - Country:US
Mailing Address - Phone:787-841-2314
Mailing Address - Fax:
Practice Address - Street 1:1124 AVE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-0643
Practice Address - Country:US
Practice Address - Phone:787-841-2314
Practice Address - Fax:787-844-5484
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11319174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084248Medicare ID - Type Unspecified
PRG40927Medicare UPIN