Provider Demographics
NPI:1659341998
Name:GONZALEZ, LUIS GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:GUSTAVO
Last Name:GONZALEZ
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:PO BOX 2627
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-2627
Mailing Address - Country:US
Mailing Address - Phone:336-951-1010
Mailing Address - Fax:
Practice Address - Street 1:618 S MAIN ST
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5020
Practice Address - Country:US
Practice Address - Phone:336-951-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000031135207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8926472Medicaid
NCC82274Medicare UPIN
NC8926472Medicaid