Provider Demographics
NPI:1649404195
Name:DETRES, JAVIETH H (MD)
Entity Type:Individual
Prefix:
First Name:JAVIETH
Middle Name:H
Last Name:DETRES
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:D STREET 155
Mailing Address - Street 2:MARBELLA
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00921-3200
Mailing Address - Country:US
Mailing Address - Phone:787-240-4646
Mailing Address - Fax:787-848-0318
Practice Address - Street 1:100 AVE LUIS MUNOZ MARIN
Practice Address - Street 2:URB MARIOLGA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-6184
Practice Address - Country:US
Practice Address - Phone:787-240-4646
Practice Address - Fax:787-848-0318
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRGQ436AMedicare PIN