Provider Demographics
NPI:1720070055
Name:GONZALEZ, CARLOS M (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:GONZALEZ
Suffix:
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:URB CIUDAD JARDIN APARTADO 265
Mailing Address - Street 2:A63 CALLE SIEMPREVIVA
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-0265
Mailing Address - Country:US
Mailing Address - Phone:787-757-7030
Mailing Address - Fax:787-757-7030
Practice Address - Street 1:CALLE 24 BLOQ. 11 #18
Practice Address - Street 2:VILLA CAROLINA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:US
Practice Address - Phone:787-757-7030
Practice Address - Fax:787-757-7030
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5773208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C84108Medicare UPIN
97453Medicare ID - Type Unspecified