Healthcare Provider Details

I. General information

NPI: 1679660260
Provider Name (Legal Business Name): LUIS ALBERTO GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LUIS ALBERTO VAZQUEZ

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 LAKE CITY HWY
WARSAW IN
46580-3942
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-4144
  • Fax: 574-268-2281
Mailing address:
  • Phone: 517-364-6253
  • Fax: 517-364-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301054514
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01080663A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: