Provider Demographics
NPI:1447557202
Name:GONZALES, LOUIS FLORENTINE (IDC)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:FLORENTINE
Last Name:GONZALES
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28K QUEEN MARY CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619-2528
Mailing Address - Country:US
Mailing Address - Phone:301-312-5243
Mailing Address - Fax:
Practice Address - Street 1:28K QUEEN MARY CT
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2528
Practice Address - Country:US
Practice Address - Phone:301-312-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman