Provider Demographics
NPI:1770797680
Name:GONZALES, MA. LOURDES C (MD)
Entity type:Individual
Prefix:DR
First Name:MA. LOURDES
Middle Name:C
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:94 VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4236
Mailing Address - Country:US
Mailing Address - Phone:516-472-1710
Mailing Address - Fax:
Practice Address - Street 1:17541 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5724
Practice Address - Country:US
Practice Address - Phone:516-472-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2437132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
243713OtherLICENSE