Provider Demographics
NPI:1124650973
Name:MARTINEZ TELLADO, GIANCARLO
Entity type:Individual
Prefix:
First Name:GIANCARLO
Middle Name:
Last Name:MARTINEZ TELLADO
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:COOPERATIVA JARDINES DE SAN IGNACIO
Mailing Address - Street 2:CALLE SAN GUILLERMO APARTAMENTO 1909A
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927
Mailing Address - Country:US
Mailing Address - Phone:787-909-2840
Mailing Address - Fax:
Practice Address - Street 1:COOPERATIVA JARDINES DE SAN IGNACIO
Practice Address - Street 2:CALLE SAN GUILLERMO APARTAMENTO 1909A
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927
Practice Address - Country:US
Practice Address - Phone:787-909-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR403184602390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program