Healthcare Provider Details

I. General information

NPI: 1073440707
Provider Name (Legal Business Name): JORGE LUIS GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 AVE LAUREL
BAYAMON PR
00956-4816
US

IV. Provider business mailing address

131 RIVERWALK
TRUJILLO ALTO PR
00976-6214
US

V. Phone/Fax

Practice location:
  • Phone: 787-798-3001
  • Fax:
Mailing address:
  • Phone: 787-504-5595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number6833692
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: