Healthcare Provider Details

I. General information

NPI: 1346212453
Provider Name (Legal Business Name): OSVALDO JOSE SANTIAGO GONZALEZ MDFACS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EL SENORIAL PLZ 1326 SALUD ST SUITE 121
PONCE PR
00728-1689
US

IV. Provider business mailing address

PO BOX 801148
COTO LAUREL PR
00780-1148
US

V. Phone/Fax

Practice location:
  • Phone: 787-259-7077
  • Fax: 787-259-7026
Mailing address:
  • Phone: 787-259-7077
  • Fax: 787-259-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number8529
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: