1619636982 NPI number — WILSON MARTELL JOVET

Table of content: WILSON MARTELL JOVET (NPI 1619636982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619636982 NPI number — WILSON MARTELL JOVET

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTELL JOVET
Provider First Name:
WILSON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619636982
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 94
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROLINA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00986-0094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-776-3511
Provider Business Mailing Address Fax Number:
787-757-2039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVENIDA JOSE FIDALGO DIAZ
Provider Second Line Business Practice Location Address:
4SS6 VILLA FONTANA
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-776-3511
Provider Business Practice Location Address Fax Number:
787-757-2039
Provider Enumeration Date:
12/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FJ487A , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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