1043266869 NPI number — LUIS F GONZALEZ M.D.

Table of content: LUIS F GONZALEZ M.D. (NPI 1043266869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043266869 NPI number — LUIS F GONZALEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
LUIS
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043266869
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-6170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-524-1058
Provider Business Mailing Address Fax Number:
802-524-1289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 FAIRFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST ALBANS
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05478-1726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-524-1058
Provider Business Practice Location Address Fax Number:
802-524-1289
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  042-0009728 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0VN1883 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300123221 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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