Provider Demographics
NPI:1164425997
Name:GONZALES, LUISITO C (MD)
Entity Type:Individual
Prefix:DR
First Name:LUISITO
Middle Name:C
Last Name:GONZALES
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:SUITE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3338
Practice Address - Fax:574-296-3332
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046919A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200138970Medicaid
INP01317343OtherRR MEDICARE
IN000000691249OtherANTHEM BCBS
IN200148970Medicaid
IN000000851248OtherBCBS ELKHART CARDIOLOGY
INM400034179Medicare PIN
ING60383Medicare UPIN
IN200138970Medicaid
IN236040059Medicare PIN