Healthcare Provider Details

I. General information

NPI: 1881994770
Provider Name (Legal Business Name): JAVIER GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 07/21/2022
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL EPISCOPAL SAN LUCAS PONCE AVE TITO CASTRO, NUM. 917 PO BOX 336810
PONCE PR
00733
US

IV. Provider business mailing address

1225 BLVD SAN LUIS H13 URB VILLAS DE LAUREL I
COTO LAUREL, PONCE PR
00780
US

V. Phone/Fax

Practice location:
  • Phone: 787-843-3031
  • Fax:
Mailing address:
  • Phone: 305-992-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105692
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number33161R
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME143212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: