Provider Demographics
NPI:1396310439
Name:SANCHEZ-MALDONADO, MERVIN
Entity type:Individual
Prefix:
First Name:MERVIN
Middle Name:
Last Name:SANCHEZ-MALDONADO
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:URB MONTE CLARO MA-36
Mailing Address - Street 2:PLAZA 7
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-658-6218
Mailing Address - Fax:787-658-7116
Practice Address - Street 1:536 AVE VICTORIA UBR GARCIA
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-658-6218
Practice Address - Fax:787-658-7116
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR70Medicaid