Provider Demographics
NPI:1619946035
Name:GARAYALDE, GLENN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JOSEPH
Last Name:GARAYALDE
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:PO BOX 361976
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-1976
Mailing Address - Country:US
Mailing Address - Phone:787-723-1735
Mailing Address - Fax:787-723-1736
Practice Address - Street 1:1452 ASHFORD AVE
Practice Address - Street 2:SUITE 411 A CONDO ADA LIGIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-723-1735
Practice Address - Fax:787-723-1736
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR62292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD26664Medicare UPIN
PR0097836Medicare ID - Type Unspecified