Provider Demographics
NPI:1881766285
Name:GONZALEZ, LUIS EDGARDO (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EDGARDO
Last Name:GONZALEZ
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:COND. ANDREA'S COURT
Mailing Address - Street 2:370 CALLE 10 APT. 3
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-475-6425
Mailing Address - Fax:
Practice Address - Street 1:VA MEDICAL CENTER
Practice Address - Street 2:10 CALLE CASIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3201
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15,562208100000X
NY238,357208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation