MEDICARE: LUIS F GONZALEZ, III, MD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073516126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUIS F GONZALEZ, III, MD, PC

Provider Business Mailing Address
First Line	:	118 CONSUMER SQ
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-6507
Country	:	US
Telephone Number	:	518-562-3650
Fax Number	:	518-562-3801

Provider Business Practice Location Address
First Line	:	118 CONSUMER SQ
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-6507
Country	:	US
Telephone Number	:	518-562-3650
Fax Number	:	518-562-3801

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MRS. MICHELLE DOUGLAS
Credential	:
Telephone Number	:	502-477-1815

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/12/2008

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