Provider Demographics
NPI:1902395601
Name:GONZALEZ MOSQUERA, LUIS FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:GONZALEZ MOSQUERA
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 1:2800 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2610
Mailing Address - Country:US
Mailing Address - Phone:888-777-4167
Mailing Address - Fax:313-916-4989
Practice Address - Street 1:2800 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2610
Practice Address - Country:US
Practice Address - Phone:888-777-4167
Practice Address - Fax:313-916-4989
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351048906390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program