Provider Demographics
NPI:1467092536
Name:GONZALEZ, ANGEL LUIS JR
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LUIS
Last Name:GONZALEZ
Suffix:JR
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:HC 2 BOX 4836
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-9586
Mailing Address - Country:US
Mailing Address - Phone:787-322-0071
Mailing Address - Fax:
Practice Address - Street 1:#8 CALLE AGUSTIN COLON PACHECO
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:PR
Practice Address - Zip Code:00751
Practice Address - Country:US
Practice Address - Phone:787-824-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12363183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6179205OtherDRIVER LICENSE