1629016563 NPI number — MR. EFRAIN GONZALEZ-GRAJALES

Table of content: MR. EFRAIN GONZALEZ-GRAJALES (NPI 1629016563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629016563 NPI number — MR. EFRAIN GONZALEZ-GRAJALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ-GRAJALES
Provider First Name:
EFRAIN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1629016563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 02 BOX 21953
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AGUADILLA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00603-0507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-460-9077
Provider Business Mailing Address Fax Number:
787-252-1385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 125, KM 05 INT
Provider Second Line Business Practice Location Address:
CAMINO CORDERO, BO. PALMAR
Provider Business Practice Location Address City Name:
AGUADILLA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-460-9077
Provider Business Practice Location Address Fax Number:
787-252-1385
Provider Enumeration Date:
06/03/2006

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: 3416L0300X , with the licence number:  P1080 , 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: 70521 . This is a "PREFERRED MEDICARE CHOICE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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