Healthcare Provider Details

I. General information

NPI: 1750394078
Provider Name (Legal Business Name): SASHA MARA GONZALEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARCELONETA PRIME OUTLETS CARR.#2 KM. 54.6 INTERSECCION CARR. 140 , BO. MANATI ABAJO
BARCELONETA PR
00617
US

IV. Provider business mailing address

425 CARR 693 PMB #194
DORADO PR
00646-4802
US

V. Phone/Fax

Practice location:
  • Phone: 787-607-1223
  • Fax: 787-626-4708
Mailing address:
  • Phone: 787-549-1818
  • Fax: 787-626-4708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15605
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: