Provider Demographics
NPI:1629427273
Name:MENA-GONZALEZ, CONSUELO AMALIA (MD)
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:AMALIA
Last Name:MENA-GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:AMALIA
Other - Last Name:MENA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:712 CALLE CENTRAL APT 601
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-4151
Mailing Address - Country:US
Mailing Address - Phone:310-600-7783
Mailing Address - Fax:939-336-2476
Practice Address - Street 1:712 CALLE CENTRAL APT 601
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-4151
Practice Address - Country:US
Practice Address - Phone:310-600-7783
Practice Address - Fax:939-336-2476
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine