Provider Demographics
NPI:1992842090
Name:GOMEZ-FORTUNA, MAIRALISA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAIRALISA
Middle Name:
Last Name:GOMEZ-FORTUNA
Suffix:
Gender:F
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:P.O. BOX 1405
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729
Mailing Address - Country:US
Mailing Address - Phone:787-876-0849
Mailing Address - Fax:787-876-0849
Practice Address - Street 1:CALLE PALMER # 8
Practice Address - Street 2:ESQUINA CALDERON MUJICA
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-876-0849
Practice Address - Fax:787-876-0849
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9438208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice