Provider Demographics
NPI:1932516465
Name:DR. JORGE R. MATTA GONZALEZ CSP
Entity Type:Organization
Organization Name:DR. JORGE R. MATTA GONZALEZ CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATTA GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-340-0060
Mailing Address - Street 1:PO BOX 9634
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-9634
Mailing Address - Country:US
Mailing Address - Phone:787-340-0060
Mailing Address - Fax:
Practice Address - Street 1:QUADRANGLE MEDICAL CENTER
Practice Address - Street 2:50 LUIS MUNOZ MARIN SUITE 305
Practice Address - City:CAGUAS
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00725-0000
Practice Address - Country:UM
Practice Address - Phone:787-744-0857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR340350261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health