Healthcare Provider Details

I. General information

NPI: 1841600624
Provider Name (Legal Business Name): SAN LAZARGERD MEDICAL II CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 129 KM 21.2
LARES PR
00669-0000
US

IV. Provider business mailing address

PO BOX 428
LARES PR
00669-0428
US

V. Phone/Fax

Practice location:
  • Phone: 787-897-0353
  • Fax: 787-897-3979
Mailing address:
  • Phone: 787-897-0353
  • Fax: 787-897-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13643
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GERALDO GONZALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-897-0353