Healthcare Provider Details

I. General information

NPI: 1871584490
Provider Name (Legal Business Name): EDGARDO LUIS GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S7-12 CALLE 6 URB PARANA
SAN JUAN PR
00926-6129
US

IV. Provider business mailing address

S7-12 CALLE 6 URB PARANA
SAN JUAN PR
00926-6129
US

V. Phone/Fax

Practice location:
  • Phone: 787-579-6425
  • Fax:
Mailing address:
  • Phone: 787-579-6425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number15965
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: