Provider Demographics
NPI:1720184385
Name:DRA MADELINE FERNANDEZ GONZALEZ CSP
Entity Type:Organization
Organization Name:DRA MADELINE FERNANDEZ GONZALEZ CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-843-0003
Mailing Address - Street 1:2431 BLVD LUIS A FERRE
Mailing Address - Street 2:EDIFICIO PORRATA PILA STE 311
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-2113
Mailing Address - Country:US
Mailing Address - Phone:787-843-0003
Mailing Address - Fax:787-841-1086
Practice Address - Street 1:2431 BLVD LUIS A FERRE
Practice Address - Street 2:EDIFICIO PORRATA PILA STE 311
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2113
Practice Address - Country:US
Practice Address - Phone:787-843-0003
Practice Address - Fax:787-843-0003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR89957Medicare ID - Type Unspecified
PRG90632Medicare UPIN