Provider Demographics
NPI:1164406096
Name:GONZALEZ ESCLAVON, EDNA L (MD)
Entity Type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:L
Last Name:GONZALEZ ESCLAVON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE COLON
Mailing Address - Street 2:#311
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602
Mailing Address - Country:US
Mailing Address - Phone:787-868-3530
Mailing Address - Fax:787-868-3530
Practice Address - Street 1:CALLE COLON
Practice Address - Street 2:#311
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602
Practice Address - Country:US
Practice Address - Phone:787-868-3530
Practice Address - Fax:787-868-3530
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5604208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C79296Medicare UPIN
23202Medicare ID - Type Unspecified