Provider Demographics
NPI:1285757898
Name:GASTRO MED, CSP
Entity type:Organization
Organization Name:GASTRO MED, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:RAFAEL
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-878-1900
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613-0411
Mailing Address - Country:US
Mailing Address - Phone:787-878-1908
Mailing Address - Fax:787-878-0421
Practice Address - Street 1:58 AVE BARBOSA
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4378
Practice Address - Country:US
Practice Address - Phone:787-878-1900
Practice Address - Fax:787-878-0421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4624207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR96208Medicare ID - Type UnspecifiedNUMERO DE PROVEEDOR
PRC78148Medicare UPIN