Provider Demographics
NPI:1699785741
Name:BELMONT RODRIGUEZ, WALLACE (MD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:BELMONT RODRIGUEZ
Suffix:
Gender:M
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:PO BOX 5364
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-5364
Mailing Address - Country:US
Mailing Address - Phone:787-746-6466
Mailing Address - Fax:787-258-3135
Practice Address - Street 1:AVE MUNOZ MARIN I 17 URB VILLA CARMEN
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726-5364
Practice Address - Country:US
Practice Address - Phone:787-746-6466
Practice Address - Fax:787-258-3135
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7976207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE46332Medicare UPIN
PR0081613Medicare PIN