Provider Demographics
NPI:1538441308
Name:MADERA, DEMETRIO J (PSYD)
Entity type:Individual
Prefix:MR
First Name:DEMETRIO
Middle Name:J
Last Name:MADERA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 PONCE BYP # PONCE
Mailing Address - Street 2:PASEO DEL VETERANO 1010
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-0300
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:
Practice Address - Street 1:1010 PASEO DEL VETERANO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2001
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004574103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program