Provider Demographics
NPI:1831272350
Name:GONZALEZ, VIRGINIA YAJAIRA (MD)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:YAJAIRA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 FORSYTHE AVE STE 333 PMB
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3540
Mailing Address - Country:US
Mailing Address - Phone:318-338-3540
Mailing Address - Fax:318-335-3542
Practice Address - Street 1:402 MCMILLAN ROAD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5326
Practice Address - Country:US
Practice Address - Phone:318-338-3540
Practice Address - Fax:318-335-3542
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11314R207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1667781Medicaid
LAG19986Medicare UPIN
LA5W448Medicare PIN