Provider Demographics
NPI:1619636982
Name:MARTELL JOVET, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:MARTELL JOVET
Suffix:
Gender:M
Credentials:
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 94
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00986-0094
Mailing Address - Country:US
Mailing Address - Phone:787-776-3511
Mailing Address - Fax:787-757-2039
Practice Address - Street 1:AVENIDA JOSE FIDALGO DIAZ
Practice Address - Street 2:4SS6 VILLA FONTANA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983
Practice Address - Country:US
Practice Address - Phone:787-776-3511
Practice Address - Fax:787-757-2039
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRFJ487AMedicaid