Provider Demographics
NPI:1659465680
Name:MONTALVO, ELIZAMA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZAMA
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:F
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:HC 7 BOX 25877
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00731-9670
Mailing Address - Country:US
Mailing Address - Phone:845-270-4234
Mailing Address - Fax:
Practice Address - Street 1:388 ZONA IND REPARADA 2
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2347
Practice Address - Country:US
Practice Address - Phone:787-840-1163
Practice Address - Fax:787-848-1306
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164035207Q00000X
PR8834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30F591Medicare ID - Type Unspecified
NYE69832Medicare UPIN