Healthcare Provider Details

I. General information

NPI: 1205483377
Provider Name (Legal Business Name): CARMEN DE LOS MILAGROS GONZALEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 11/19/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 AVE TITO CASTRO
PONCE PR
00716-4717
US

IV. Provider business mailing address

PO BOX 656
SABANA GRANDE PR
00637-0656
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-2080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34143R
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number22252
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22252
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: