Provider Demographics
NPI:1508827403
Name:GONZALEZ, IVELISSE (MD)
Entity Type:Individual
Prefix:MRS
First Name:IVELISSE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
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:#J10 6TH SREET
Mailing Address - Street 2:EL MIRADOR DE CUPEY
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-7571
Mailing Address - Country:US
Mailing Address - Phone:787-748-6277
Mailing Address - Fax:
Practice Address - Street 1:SUITE 603#68 ST. CRUZ ST
Practice Address - Street 2:TORRE SAN PABLO SUITE #603
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7035
Practice Address - Country:US
Practice Address - Phone:787-786-2469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10207208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR82563GOOtherSSS
82563Medicare ID - Type Unspecified
PR82563GOOtherSSS