Provider Demographics
NPI:1720531593
Name:CAMPO GONZALEZ, LUIS ALFONSO MARTIN DEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALFONSO MARTIN DEL
Last Name:CAMPO GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LUIS
Other - Middle Name:ALFONSO
Other - Last Name:MARTIN DEL CAMPO GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1990 FORD DR APT 602
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3954
Mailing Address - Country:US
Mailing Address - Phone:216-278-1086
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.027430390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program