Provider Demographics
NPI:1114263332
Name:MA.LOURDES CASTILLO GONZALES,MD,PC
Entity Type:Organization
Organization Name:MA.LOURDES CASTILLO GONZALES,MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MA.LOURDES
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-472-1710
Mailing Address - Street 1:94 VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4236
Mailing Address - Country:US
Mailing Address - Phone:516-472-1710
Mailing Address - Fax:
Practice Address - Street 1:17013 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4546
Practice Address - Country:US
Practice Address - Phone:516-472-1710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243713174400000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03380123Medicaid
NY243713OtherLICENSE