Provider Demographics
NPI:1073501524
Name:GONZALEZ, JOSE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:GONZALEZ
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:RE2 VIA PIEDRAS
Mailing Address - Street 2:RIO CRISTAL
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6016
Mailing Address - Country:US
Mailing Address - Phone:787-316-9862
Mailing Address - Fax:787-783-6089
Practice Address - Street 1:55 CALLE BALDORIOTY
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739-3450
Practice Address - Country:US
Practice Address - Phone:787-739-0714
Practice Address - Fax:787-739-0714
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16162208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI50651Medicare UPIN