Provider Demographics
NPI:1831318666
Name:DRA-IRIS A ACEVEDO MARTY P S C
Entity Type:Organization
Organization Name:DRA-IRIS A ACEVEDO MARTY P S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ACEVEDO MARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-882-1779
Mailing Address - Street 1:PO BOX 4240
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-4240
Mailing Address - Country:US
Mailing Address - Phone:787-882-1779
Mailing Address - Fax:787-765-0691
Practice Address - Street 1:106 AVE SEVERIANO CUEVAS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5769
Practice Address - Country:US
Practice Address - Phone:787-882-1779
Practice Address - Fax:787-765-0691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR129892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0090164Medicare ID - Type Unspecified
PRH95806Medicare UPIN