Provider Demographics
NPI:1912574799
Name:GONZALEZ, CAMILO LEOPOLDO
Entity Type:Individual
Prefix:
First Name:CAMILO
Middle Name:LEOPOLDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CALLE SOCORRO
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-1854
Mailing Address - Country:US
Mailing Address - Phone:786-420-9106
Mailing Address - Fax:
Practice Address - Street 1:62 CALLE SOCORRO
Practice Address - Street 2:
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678-1854
Practice Address - Country:US
Practice Address - Phone:786-420-9106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty