Provider Demographics
NPI:1538127014
Name:GONZALEZ DEL ROSARIO, MODESTO FERNANDO
Entity Type:Individual
Prefix:
First Name:MODESTO
Middle Name:FERNANDO
Last Name:GONZALEZ DEL ROSARIO
Suffix:
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 1:735 PONCE DE LEON
Mailing Address - Street 2:SUITE 716
Mailing Address - City:HATO REY
Mailing Address - State:PR
Mailing Address - Zip Code:00917
Mailing Address - Country:US
Mailing Address - Phone:787-765-3079
Mailing Address - Fax:787-767-7170
Practice Address - Street 1:735 PONCE DE LEON
Practice Address - Street 2:SUITE 716
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-765-3079
Practice Address - Fax:787-767-7170
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5694207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC79639Medicare UPIN
PR29146BMedicare ID - Type Unspecified