Healthcare Provider Details

I. General information

NPI: 1124025358
Provider Name (Legal Business Name): REYNALDO GOMEZ ADROVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 149 # KM1H3 RPTO VILLA ALBERTA # 2
MANATI PR
00674-9670
US

IV. Provider business mailing address

PO BOX 414
MANATI PR
00674-0414
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-6562
  • Fax: 787-884-0253
Mailing address:
  • Phone: 787-854-6562
  • Fax: 787-884-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10351
License Number StatePR

VII. Legacy identifiers

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

# 1
Identifier83156GO
Identifier TypeMEDICAID
Identifier StatePR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: