Provider Demographics
NPI:1104856103
Name:GONZALEZ GOMEZ, ALFREDO (MD)
Entity Type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:GONZALEZ GOMEZ
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:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:AGUAS BUENAS
Mailing Address - State:PR
Mailing Address - Zip Code:00703-0777
Mailing Address - Country:US
Mailing Address - Phone:787-732-4123
Mailing Address - Fax:
Practice Address - Street 1:5 CALLE ALBIZU CAMPOS
Practice Address - Street 2:
Practice Address - City:AGUAS BUENAS
Practice Address - State:PR
Practice Address - Zip Code:00703-3102
Practice Address - Country:US
Practice Address - Phone:787-732-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6692208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC77560Medicare UPIN
PR027682Medicare ID - Type Unspecified