Healthcare Provider Details

I. General information

NPI: 1588959068
Provider Name (Legal Business Name): ALBERTO LUIS GONZALEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BLUE HILLS AVE
HARTFORD CT
06112-1500
US

IV. Provider business mailing address

675 TOWER AVE STE 301
HARTFORD CT
06112-1274
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4000
  • Fax:
Mailing address:
  • Phone: 860-714-2338
  • Fax: 860-714-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number052454
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number52454
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: