Provider Demographics
NPI:1639733603
Name:MARTINEZ MONTALVO, IVELISSE
Entity Type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:
Last Name:MARTINEZ MONTALVO
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:PO BOX 193069
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-3069
Mailing Address - Country:US
Mailing Address - Phone:787-761-0036
Mailing Address - Fax:787-292-5050
Practice Address - Street 1:CARR 845 KM 2.2
Practice Address - Street 2:D36 AVE FAIRVIEW
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00919-0091
Practice Address - Country:US
Practice Address - Phone:787-761-0036
Practice Address - Fax:787-292-5050
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001487231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist