Provider Demographics
NPI:1871584490
Name:GONZALEZ, EDGARDO LUIS (MD)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:LUIS
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:S7-12 CALLE 6
Mailing Address - Street 2:URB PARANA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6129
Mailing Address - Country:US
Mailing Address - Phone:787-579-6425
Mailing Address - Fax:
Practice Address - Street 1:S7-12 CALLE 6
Practice Address - Street 2:URB PARANA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6129
Practice Address - Country:US
Practice Address - Phone:787-579-6425
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15965173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine