Healthcare Provider Details

I. General information

NPI: 1922091644
Provider Name (Legal Business Name): ANGEL B, MALAVE-GOMEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2005
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CALLE PROGRESO SUITE 202
AGUADILLA PR
00603-5000
US

IV. Provider business mailing address

PO BOX 860
MAYAGUEZ PR
00681-0860
US

V. Phone/Fax

Practice location:
  • Phone: 787-891-5229
  • Fax:
Mailing address:
  • Phone: 787-891-5229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4194
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: