Provider Demographics
NPI:1376582502
Name:GONZALEZ, AURORA (MD)
Entity Type:Individual
Prefix:
First Name:AURORA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 COMPASS POINT DR.
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301
Mailing Address - Country:US
Mailing Address - Phone:636-947-4480
Mailing Address - Fax:636-947-9860
Practice Address - Street 1:100 MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-625-5303
Practice Address - Fax:636-625-5403
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350787382085R0202X
MO20090086602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2744043Medicaid
IN200859790AMedicaid
H79830Medicare UPIN
OH2744043Medicaid
OH4204871Medicare PIN
IN200859790AMedicaid