MEDICARE: DR. JOHANS GONZALEZ 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	208D00000X	General Practice Physician	19551	PR

General Provider Information

NPI Number	:	1083072052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHANS GONZALEZ GONZALEZ M.D.

Provider Business Mailing Address
First Line	:	HC 1 BOX 4722
Second Line	:
City	:	LARES
State	:	PR
Zip	:	00669-9619
Country	:	US
Telephone Number	:	787-383-9354
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE 2 AVE SEVERINO CUEVAS 18
Second Line	:
City	:	AGUADILLA
State	:	PR
Zip	:	00605-4055
Country	:	US
Telephone Number	:	787-658-0012
Fax Number	:

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

Provider Enumeration Date	:	02/05/2016
Last Update Date	:	02/12/2017

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