Provider Demographics
NPI:1336668052
Name:GONZALEZ, JORGE L SR
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:L
Last Name:GONZALEZ
Suffix:SR
Gender:M
Credentials:
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 488
Mailing Address - Street 2:
Mailing Address - City:JAYUYA
Mailing Address - State:PR
Mailing Address - Zip Code:00664-0488
Mailing Address - Country:US
Mailing Address - Phone:787-828-0900
Mailing Address - Fax:787-828-7017
Practice Address - Street 1:19 CALLE FIGUERAS INTERSECCION CALLE ERMERINDA RIVERA
Practice Address - Street 2:
Practice Address - City:JAYUYA
Practice Address - State:PR
Practice Address - Zip Code:00664
Practice Address - Country:US
Practice Address - Phone:787-828-0900
Practice Address - Fax:787-828-7017
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTCAM-7433416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport