Provider Demographics
NPI:1467689497
Name:GONZALEZ, MARIO DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:DAVID
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. LOS MONTES
Mailing Address - Street 2:155 ZORSAL STREET
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-630-8227
Mailing Address - Fax:787-870-6904
Practice Address - Street 1:155 ZORSAL STREET
Practice Address - Street 2:URB. LOS MONTES
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646
Practice Address - Country:US
Practice Address - Phone:787-630-8227
Practice Address - Fax:787-870-6904
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist