Provider Demographics
NPI:1629087317
Name:GONZALEZ, MODESTO J (MD)
Entity Type:Individual
Prefix:
First Name:MODESTO
Middle Name:J
Last Name:GONZALEZ
Suffix:
Gender:M
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:PO BOX 250128
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00604-0128
Mailing Address - Country:US
Mailing Address - Phone:787-891-7428
Mailing Address - Fax:787-891-7428
Practice Address - Street 1:CARR 107 KM 2 9
Practice Address - Street 2:BO BORINQUEN
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-891-7428
Practice Address - Fax:787-891-7428
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6296208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC79699Medicare UPIN