Provider Demographics
NPI:1417082983
Name:MARTES, PROVIDENCIO (MS)
Entity Type:Individual
Prefix:MR
First Name:PROVIDENCIO
Middle Name:
Last Name:MARTES
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 EDIFICIO DIAZ SUITE 5
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674
Mailing Address - Country:US
Mailing Address - Phone:787-884-9289
Mailing Address - Fax:787-884-9289
Practice Address - Street 1:EXP. 149 KM 7.5
Practice Address - Street 2:600 EDIFICIO DIAZ SUITE 5
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-884-9289
Practice Address - Fax:787-884-9289
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical