Provider Demographics
NPI:1457368847
Name:GONZALEZ, JORGE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 803
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674
Mailing Address - Country:US
Mailing Address - Phone:787-262-7537
Mailing Address - Fax:787-884-7463
Practice Address - Street 1:CARR. 455 INT454 KM. 2.3
Practice Address - Street 2:
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627
Practice Address - Country:US
Practice Address - Phone:787-262-7537
Practice Address - Fax:787-884-7463
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13834208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH96850Medicare UPIN