Healthcare Provider Details

I. General information

NPI: 1295793149
Provider Name (Legal Business Name): JUAN A. ASENSIO-GONZALEZ M.D., FACS, FCCM, FR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DOUG WHITE DR STE 210
MYRTLE BEACH SC
29572-4181
US

IV. Provider business mailing address

920 DOUG WHITE DR STE 210
MYRTLE BEACH SC
29572-4181
US

V. Phone/Fax

Practice location:
  • Phone: 843-497-6348
  • Fax: 843-497-6351
Mailing address:
  • Phone: 843-497-6348
  • Fax: 843-497-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number72444
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number264501
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number28147
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME95504
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number91224
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number91224
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: