Provider Demographics
NPI:1619351947
Name:GONZALEZ VALE, JOANN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:MARIE
Last Name:GONZALEZ VALE
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 1:410 AVE HOSTOS
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-1560
Mailing Address - Country:US
Mailing Address - Phone:787-652-9200
Mailing Address - Fax:
Practice Address - Street 1:410 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-1560
Practice Address - Country:US
Practice Address - Phone:787-652-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR196452080N0001X
TXR8360208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR19645OtherLICENSE