Provider Demographics
NPI:1073590691
Name:GONZALEZ YANES, OMAR A
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:A
Last Name:GONZALEZ YANES
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:PO BOX 364792
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-4792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:735 AVE. PONCE DEL
Practice Address - Street 2:TORRE MEDICA AUXILIO MUTUO SUITE 214
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-766-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12433207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH45072Medicare UPIN