1518357664 NPI number — SANDY M. GONZALEZ M.D. P.S.C.

Table of content: (NPI 1518357664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518357664 NPI number — SANDY M. GONZALEZ M.D. P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDY M. GONZALEZ M.D. P.S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1518357664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1492 AVE PONCE DE LEON STE 709
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00907-4024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-725-0380
Provider Business Mailing Address Fax Number:
787-725-0315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1492 AVE PONCE DE LEON STE 709
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00907-4024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-725-0380
Provider Business Practice Location Address Fax Number:
787-725-0315
Provider Enumeration Date:
01/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-725-0380

Provider Taxonomy Codes

  • Taxonomy code: 2082S0105X , with the licence number:  9867 , 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)

  • Identifier: 1003946568 . This is a "TRIPLE S PUERTO RICO" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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