Provider Demographics
NPI:1376175620
Name:IRIZARRY MARTINEZ, MICHAEL ANTHONY (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:IRIZARRY MARTINEZ
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URBANIZACION PERLA DEL SUR
Mailing Address - Street 2:2421 MARGINAL PERLA DEL SUR BO. CANAS URBANO
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728
Mailing Address - Country:US
Mailing Address - Phone:939-400-8000
Mailing Address - Fax:
Practice Address - Street 1:URBANIZACION PERLA DEL SUR
Practice Address - Street 2:2421 MARGINAL PERLA DEL SUR BO. CANAS URBANO
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728
Practice Address - Country:US
Practice Address - Phone:939-400-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1225156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1225OtherOPTICIAN