Provider Demographics
NPI:1962938209
Name:GONZALEZ CARBONELL, MARIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:GONZALEZ CARBONELL
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 1:1509 AVE PONCE DE LEON
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-1771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 CALLE PALMA
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4526
Practice Address - Country:US
Practice Address - Phone:787-309-2546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314380207Y00000X
PR22947207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology