Provider Demographics
NPI:1316928625
Name:MALDONADO, JELLYTZA (MD)
Entity type:Individual
Prefix:
First Name:JELLYTZA
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 AVE PONCE DE LEON STE 106
Mailing Address - Street 2:PONCE DE LEON AVE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-3951
Mailing Address - Country:US
Mailing Address - Phone:787-250-0852
Mailing Address - Fax:787-250-0852
Practice Address - Street 1:1225 AVE PONCE DE LEON STE 106
Practice Address - Street 2:PONCE DE LEON AVE
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-3951
Practice Address - Country:US
Practice Address - Phone:787-250-0852
Practice Address - Fax:787-250-0852
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H39763Medicare UPIN
PR89931Medicare ID - Type Unspecified