Provider Demographics
NPI:1588184998
Name:OSTOLAZA VILLARRUBIA, GLORYMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORYMAR
Middle Name:
Last Name:OSTOLAZA VILLARRUBIA
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:F1-26 CALLE C
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6433
Mailing Address - Country:US
Mailing Address - Phone:787-447-8378
Mailing Address - Fax:
Practice Address - Street 1:70 URB SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-620-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR21023208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program