Provider Demographics
NPI:1861474223
Name:GONZALEZ, SAMUEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
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 177
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0177
Mailing Address - Country:US
Mailing Address - Phone:787-866-1500
Mailing Address - Fax:787-866-1570
Practice Address - Street 1:LA FUENTE TOWN CENTER
Practice Address - Street 2:MARGINAL 706 STE 11139
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-866-1500
Practice Address - Fax:787-866-1652
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121889207RH0003X
PR12702207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014027200Medicaid
H29066Medicare UPIN
20449Medicare ID - Type Unspecified