Provider Demographics
NPI:1164590816
Name:GONZALEZ, GERALDO (MD)
Entity Type:Individual
Prefix:
First Name:GERALDO
Middle Name:
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:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-0916
Mailing Address - Country:US
Mailing Address - Phone:787-897-0560
Mailing Address - Fax:
Practice Address - Street 1:CARR 129 KM 21.2
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669-0916
Practice Address - Country:US
Practice Address - Phone:787-897-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13643208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
100105WOtherMMM
20634OtherTS
1105AOtherPMC
6606242211OtherMCS
6606242211OtherMCS
PRH35861Medicare UPIN