MEDICARE: MADELINE FERNANDEZ GONZALEZ M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	11858	PR

General Provider Information

NPI Number	:	1043316607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE FERNANDEZ GONZALEZ M.D

Provider Business Mailing Address
First Line	:	EDIF A PORRATA PILA
Second Line	:	2431 BLVD LUIS A FERRE STE 311
City	:	PONCE
State	:	PR
Zip	:	00717-2116
Country	:	US
Telephone Number	:	787-843-0003
Fax Number	:	787-843-0003

Provider Business Practice Location Address
First Line	:	EDIF A PORRATA PILA
Second Line	:	2431 BLVD LUIS A FERRE STE 311
City	:	PONCE
State	:	PR
Zip	:	00717-2116
Country	:	US
Telephone Number	:	787-843-0003
Fax Number	:	787-841-1086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	02/11/2014

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