MEDICARE: MARIO ENRIQUE GONZALEZ BAUZA SR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	2010	PR

General Provider Information

NPI Number	:	1205836301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO ENRIQUE GONZALEZ BAUZA SR. MD

Provider Business Mailing Address
First Line	:	3 CALLE DEL CARMEN
Second Line	:	PO BOX 817
City	:	RIO GRANDE
State	:	PR
Zip	:	00745-3026
Country	:	US
Telephone Number	:	787-887-3259
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 CALLE DEL CARMEN
Second Line	:
City	:	RIO GRANDE
State	:	PR
Zip	:	00745-3026
Country	:	US
Telephone Number	:	787-887-3259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	07/08/2007

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