Provider Demographics
NPI:1912951286
Name:GONZALEZ, MICHELLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16-20 PASEO DE LA ALHAMBRA
Mailing Address - Street 2:TORRIMAR
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-3118
Mailing Address - Country:US
Mailing Address - Phone:787-783-9554
Mailing Address - Fax:
Practice Address - Street 1:AVE PONCE DE LEON
Practice Address - Street 2:PARADA 37 1/2 #715
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-1000
Practice Address - Country:US
Practice Address - Phone:787-758-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1112597OtherACAA
PR23231GOOtherTRIPLE S
PR23231Medicare ID - Type Unspecified