Provider Demographics
NPI:1205836301
Name:GONZALEZ BAUZA, MARIO ENRIQUE SR (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ENRIQUE
Last Name:GONZALEZ BAUZA
Suffix:SR
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 1:3 CALLE DEL CARMEN
Mailing Address - Street 2:PO BOX 817
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-3026
Mailing Address - Country:US
Mailing Address - Phone:787-887-3259
Mailing Address - Fax:
Practice Address - Street 1:3 CALLE DEL CARMEN
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745-3026
Practice Address - Country:US
Practice Address - Phone:787-887-3259
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2010208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C79234 PRMedicare UPIN
0022098Medicare ID - Type Unspecified