Provider Demographics
NPI:1295793628
Name:GONZALEZ, LUIS A (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 541216
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-1216
Mailing Address - Country:US
Mailing Address - Phone:321-450-1061
Mailing Address - Fax:321-453-0866
Practice Address - Street 1:270 N SYKES CREEK PKWY
Practice Address - Street 2:UNIT 108
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-452-1061
Practice Address - Fax:321-453-0866
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME60685208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057773100Medicaid
FL17673OtherBLUE CROSS BLUE SHIELD FL
FL17673OtherBLUE CROSS BLUE SHIELD FL
FL591263689OtherTAX ID NUMBER