1043702640 NPI number — DR. MARYELIS GONZALEZ PHARMD

Table of content: DR. MARYELIS GONZALEZ PHARMD (NPI 1043702640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043702640 NPI number — DR. MARYELIS GONZALEZ PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
MARYELIS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043702640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1596
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AGUADA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00602-1596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-507-0886
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CARR 402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANASCO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00610-2017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-229-1150
Provider Business Practice Location Address Fax Number:
787-229-1160
Provider Enumeration Date:
05/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  006166 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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