Provider Demographics
NPI:1790789485
Name:MARTINEZ-GONZALEZ, MANUEL ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ANTONIO
Last Name:MARTINEZ-GONZALEZ
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 1:2431 LAS AMERICAS AVE.
Mailing Address - Street 2:SUITE 308
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-2116
Mailing Address - Country:US
Mailing Address - Phone:787-844-9442
Mailing Address - Fax:787-844-9444
Practice Address - Street 1:2431 LAS AMERICAS AVE.
Practice Address - Street 2:SUITE 308
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2116
Practice Address - Country:US
Practice Address - Phone:787-844-9442
Practice Address - Fax:787-844-9444
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11766174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG41775Medicare UPIN
PR87814Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER