=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629436472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GT PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2016
-----------------------------------------------------
Last Update Date | 02/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | U3-4 CARR 21
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00921-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-800-9959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 363161
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00936-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-800-9959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARIO ROBERTO GONZALEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-800-9959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 17603
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 17603
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------