Provider Demographics
NPI:1780974063
Name:TAVAREZ GONZALEZ, LUIS T (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:T
Last Name:TAVAREZ 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 366255
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-6255
Mailing Address - Country:US
Mailing Address - Phone:787-425-0525
Mailing Address - Fax:
Practice Address - Street 1:107 AVE ORTEGON STE 100
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966-2516
Practice Address - Country:US
Practice Address - Phone:787-425-0525
Practice Address - Fax:787-425-0526
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18155207Q00000X, 208D00000X, 390200000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program