Provider Demographics
NPI:1841443553
Name:GORROCHATEGUI, MARTIN I
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:I
Last Name:GORROCHATEGUI
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 1:660 CALLE ESTADO APT A
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-3533
Mailing Address - Country:US
Mailing Address - Phone:305-297-4377
Mailing Address - Fax:888-350-0180
Practice Address - Street 1:1760 CALLE LOIZA
Practice Address - Street 2:STE 205
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00911-1867
Practice Address - Country:US
Practice Address - Phone:305-297-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR173662085R0204X, 261QR0200X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHW105ZMedicare UPIN
PRHW105AMedicare UPIN