Provider Demographics
NPI:1700891439
Name:MEDICAL FAMILY PRACTICE CTR CSP
Entity Type:Organization
Organization Name:MEDICAL FAMILY PRACTICE CTR CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-817-0573
Mailing Address - Street 1:PO BOX 142529
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-2529
Mailing Address - Country:US
Mailing Address - Phone:787-817-0573
Mailing Address - Fax:787-816-0219
Practice Address - Street 1:G5 CALLE MARGINAL
Practice Address - Street 2:URB VISTA AZUL
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-2546
Practice Address - Country:US
Practice Address - Phone:787-817-0573
Practice Address - Fax:787-816-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1700891439OtherCHAMPVA
PR1700891439OtherMAPFRE
PR1700891439OtherMAPFRE MEDICARE EXCEL
PR84396OtherSSS
PR1700891439OtherMMM HEALTHCARE
PR1700891439OtherAARP
PR1700891439OtherMCS
PR1700891439OtherPMC
PR1700891439OtherUNITED HEALTH CARE
PRDU442AOtherMEDICARE PTAN
PR1700891439OtherAMPR
PR1700891439OtherTRICARE
PR16098OtherAHM
PR1700891439OtherGLOBAL HEALTH PLAN
PR1700891439OtherMCS CLASSICARE