Provider Demographics
NPI:1649770553
Name:MARTINEZ RODRIGUEZ, MICHAEL WALLACE
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WALLACE
Last Name:MARTINEZ RODRIGUEZ
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:HC 3 BOX 11885
Mailing Address - Street 2:
Mailing Address - City:JUANA DIAZ
Mailing Address - State:PR
Mailing Address - Zip Code:00795-9579
Mailing Address - Country:US
Mailing Address - Phone:939-325-7523
Mailing Address - Fax:
Practice Address - Street 1:COLINAS DEL PRADO
Practice Address - Street 2:57 CALLE REY CARLOS
Practice Address - City:JUANA DIAZ
Practice Address - State:PR
Practice Address - Zip Code:00795
Practice Address - Country:US
Practice Address - Phone:939-325-7523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19848208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice