Provider Demographics
NPI:1679640254
Name:HIDALGO, GONZALO IVAR (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:IVAR
Last Name:HIDALGO
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 1:3311 PRESCOTT RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3900
Mailing Address - Country:US
Mailing Address - Phone:318-443-0490
Mailing Address - Fax:318-443-0690
Practice Address - Street 1:3311 PRESCOTT RD
Practice Address - Street 2:SUITE 216
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3900
Practice Address - Country:US
Practice Address - Phone:318-443-0490
Practice Address - Fax:318-443-0690
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025214174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1108162Medicaid
LAH51389Medicare UPIN
LA1108162Medicaid