Provider Demographics
NPI:1477542322
Name:MARTINEZ FERNANDEZ, JOSE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:MARTINEZ FERNANDEZ
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 1:400 AVE DOMENECH
Mailing Address - Street 2:STE 413
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3710
Mailing Address - Country:US
Mailing Address - Phone:787-753-7383
Mailing Address - Fax:787-753-7586
Practice Address - Street 1:400 AVE DOMENECH
Practice Address - Street 2:STE 413
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3710
Practice Address - Country:US
Practice Address - Phone:787-753-7383
Practice Address - Fax:787-753-7586
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6062207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D26637Medicare UPIN
PR0097630Medicare PIN