Provider Demographics
NPI:1538262183
Name:GONZALEZ FUENTES, CARLOS RUBEN (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:RUBEN
Last Name:GONZALEZ FUENTES
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:PO BOX 29005
Mailing Address - Street 2:PMB 620
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00929-0005
Mailing Address - Country:US
Mailing Address - Phone:787-755-3894
Mailing Address - Fax:787-757-3128
Practice Address - Street 1:923 AVE CAMPO RICO
Practice Address - Street 2:COUNTRY CLUB
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:787-750-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I1818-2Medicare UPIN