Healthcare Provider Details

I. General information

NPI: 1992781116
Provider Name (Legal Business Name): GONZALEZ-DIEZ OTOLARYNGOLOGY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 AVE MIRAMAR SUITE 3
ARECIBO PR
00612-4364
US

IV. Provider business mailing address

PO BOX 9945
ARECIBO PR
00613-9945
US

V. Phone/Fax

Practice location:
  • Phone: 787-880-5031
  • Fax: 787-879-4461
Mailing address:
  • Phone: 787-880-5043
  • Fax: 787-817-8861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number08699
License Number StatePR

VIII. Authorized Official

Name: MARIANO ENRIQUE GONZALEZ-DIEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-880-5031