Provider Demographics
NPI:1073516126
Name:LUIS F GONZALEZ, III, MD, PC
Entity Type:Organization
Organization Name:LUIS F GONZALEZ, III, MD, PC
Other - Org Name:CHAMPLAIN VALLEY OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-477-1815
Mailing Address - Street 1:118 CONSUMER SQ
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-6507
Mailing Address - Country:US
Mailing Address - Phone:518-562-3650
Mailing Address - Fax:518-562-3801
Practice Address - Street 1:118 CONSUMER SQ
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6507
Practice Address - Country:US
Practice Address - Phone:518-562-3650
Practice Address - Fax:518-562-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1718890Medicaid
NYAA1124Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER