Provider Demographics
NPI:1679660260
Name:GONZALEZ, LUIS ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALBERTO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:ALBERTO
Other - Last Name:VAZQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6208
Practice Address - Street 1:3505 LAKE CITY HWY
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3942
Practice Address - Country:US
Practice Address - Phone:574-269-4144
Practice Address - Fax:574-268-2281
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054514207V00000X
IN01080663A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4288420Medicaid
MI1603304641OtherBCBS INDIVIDUAL PIN
MI2868162Medicaid
MIOC36317029Medicare ID - Type Unspecified
MI2868162Medicaid
MID84721Medicare UPIN