Healthcare Provider Details

I. General information

NPI: 1558352609
Provider Name (Legal Business Name): FERNANDO LUIS GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 12/15/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801
US

IV. Provider business mailing address

611 W. PARK ST. FAPC
URBANA IL
61801-5045
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD2012-0231
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01060971A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-083284
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: