Provider Demographics
NPI:1124426242
Name:GONZALEZ, CARLOS JACOBO SR (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JACOBO
Last Name:GONZALEZ
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2367 CALLE LOMA
Mailing Address - Street 2:URB. VALLE ALTO
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-4146
Mailing Address - Country:US
Mailing Address - Phone:787-595-0612
Mailing Address - Fax:
Practice Address - Street 1:2367 CALLE LOMA
Practice Address - Street 2:URB. VALLE ALTO
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-4146
Practice Address - Country:US
Practice Address - Phone:787-595-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-06
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13614172V00000X
PR19154172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker