Healthcare Provider Details

I. General information

NPI: 1720070055
Provider Name (Legal Business Name): CARLOS M GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/25/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 24 BLOQ. 11 #18 VILLA CAROLINA
CAROLINA PR
00985
US

IV. Provider business mailing address

URB CIUDAD JARDIN APARTADO 265 A63 CALLE SIEMPREVIVA
CANOVANAS PR
00729-0265
US

V. Phone/Fax

Practice location:
  • Phone: 787-757-7030
  • Fax: 787-757-7030
Mailing address:
  • Phone: 787-757-7030
  • Fax: 787-757-7030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5773
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: