Provider Demographics
NPI:1487772414
Name:MELENDEZ, MARCO ANTONIO (PT)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:MELENDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CALLE RIO LAJAS
Mailing Address - Street 2:MONTE CASINO HEIGTHS
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-3750
Mailing Address - Country:US
Mailing Address - Phone:787-779-2274
Mailing Address - Fax:787-251-5533
Practice Address - Street 1:CARR.863 KM. 2.2
Practice Address - Street 2:BO. PAJAROS CANDELARIA
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-251-5533
Practice Address - Fax:787-251-5533
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRQ09669Medicare UPIN
PR0068140Medicare ID - Type Unspecified