Provider Demographics
NPI:1124047279
Name:GONZALEZ SAC, ADOLFO
Entity type:Individual
Prefix:DR
First Name:ADOLFO
Middle Name:
Last Name:GONZALEZ SAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 CALLE ALMIRANTE
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-6242
Mailing Address - Country:US
Mailing Address - Phone:787-241-6256
Mailing Address - Fax:
Practice Address - Street 1:408 CALLE ALMIRANTE
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-6242
Practice Address - Country:US
Practice Address - Phone:787-241-6256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12955208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0090248OtherPTAN MEDICARE
PRH67161Medicare UPIN