Provider Demographics
NPI:1093757858
Name:GONZALEZ, LUIS RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:RAFAEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:RAFAEL
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:58 AVE BARBOSA
Mailing Address - Street 2:PO BOX 411
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612-4378
Mailing Address - Country:US
Mailing Address - Phone:787-878-1908
Mailing Address - Fax:787-878-0421
Practice Address - Street 1:58 AVE BARBOSA
Practice Address - Street 2:58
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4378
Practice Address - Country:US
Practice Address - Phone:787-878-1908
Practice Address - Fax:787-878-0421
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4624207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR96208Medicare ID - Type Unspecified