Provider Demographics
NPI:1467010579
Name:NIEVES MARTINEZ, ILEANA MARIE
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:MARIE
Last Name:NIEVES MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1976 CALLE SALVIA
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-3943
Mailing Address - Country:US
Mailing Address - Phone:787-789-6940
Mailing Address - Fax:
Practice Address - Street 1:1114 AVE JESUS T PINERO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-1722
Practice Address - Country:US
Practice Address - Phone:787-781-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN68067207W00000X, 207W00000X
PR24080207WX0110X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program