MEDICARE: GONMAC LLC

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

General Provider Information

NPI Number	:	1477152049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONMAC LLC

Provider Business Mailing Address
First Line	:	PO BOX 372346
Second Line	:
City	:	CAYEY
State	:	PR
Zip	:	00737-2346
Country	:	US
Telephone Number	:	787-738-6444
Fax Number	:

Provider Business Practice Location Address
First Line	:	AVE. BALDORIOTY EDIFICIO #7
Second Line	:
City	:	CAYEY
State	:	PR
Zip	:	00736-3761
Country	:	US
Telephone Number	:	787-738-6444
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSE M GONZALEZ MACLEAN
Credential	:	MD
Telephone Number	:	787-738-6444

Provider Enumeration Date	:	10/23/2020
Last Update Date	:	10/23/2020

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