Provider Demographics
NPI:1073148912
Name:GONZALEZ BURGOS, BENJAMIN ARMANDO
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ARMANDO
Last Name:GONZALEZ BURGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 8014
Mailing Address - Street 2:
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-9860
Mailing Address - Country:US
Mailing Address - Phone:939-243-7946
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:939-243-7946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR023696208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program