Provider Demographics
NPI:1639244551
Name:MONTALVO CARRION, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:MONTALVO CARRION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 PLAZA CINCO
Mailing Address - Street 2:URB. GRAN VISTA II
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-725-4403
Mailing Address - Fax:787-273-1849
Practice Address - Street 1:CARR 172 URB TURABO GARDENS
Practice Address - Street 2:HOSPITAL SAN JUAN BAUTISTA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-746-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12451208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
89521Medicare ID - Type Unspecified