1124113899 NPI number — VICTOR M GORDO GONZALEZ SR. MD

Table of content: VICTOR M GORDO GONZALEZ SR. MD (NPI 1124113899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124113899 NPI number — VICTOR M GORDO GONZALEZ SR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDO GONZALEZ
Provider First Name:
VICTOR
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1124113899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
COND SAN FRANCISCO JAVIER NUM 406
Provider Second Line Business Mailing Address:
CALLE SAN JOSE NUM 50
Provider Business Mailing Address City Name:
GUAYNABO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-756-8186
Provider Business Mailing Address Fax Number:
787-281-0036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVE PONCE DE LEON # 708
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00918-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-756-8186
Provider Business Practice Location Address Fax Number:
787-281-0036
Provider Enumeration Date:
10/04/2006

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: 207R00000X , with the licence number:  9049 , 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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