Provider Demographics
NPI:1437157096
Name:MONTALVO, GARY GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:GEORGE
Last Name:MONTALVO
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 1:400 AVE DOMENECH
Mailing Address - Street 2:STE 506
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3710
Mailing Address - Country:US
Mailing Address - Phone:787-754-8625
Mailing Address - Fax:787-746-6650
Practice Address - Street 1:400 AVE DOMENECH
Practice Address - Street 2:STE 506
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3710
Practice Address - Country:US
Practice Address - Phone:787-754-8625
Practice Address - Fax:787-746-6650
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5622207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E10166Medicare UPIN
97292Medicare ID - Type Unspecified