1124136643 NPI number — LUZ ESTRADA GONZALEZ DPM

Table of content: LUZ ESTRADA GONZALEZ DPM (NPI 1124136643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124136643 NPI number — LUZ ESTRADA GONZALEZ DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESTRADA GONZALEZ
Provider First Name:
LUZ
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1124136643
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6734 SELFRIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375-5739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-767-9004
Provider Business Mailing Address Fax Number:
718-649-6426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9413 FLATLANDS AVENUE
Provider Second Line Business Practice Location Address:
201 E
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11236-3741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-649-6464
Provider Business Practice Location Address Fax Number:
718-649-6426
Provider Enumeration Date:
08/25/2006

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: 213E00000X , with the licence number:  N004883 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6200631 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01514323 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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