Healthcare Provider Details

I. General information

NPI: 1447557202
Provider Name (Legal Business Name): LOUIS FLORENTINE GONZALES IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28K QUEEN MARY CT
CHESTER MD
21619-2528
US

IV. Provider business mailing address

28K QUEEN MARY CT
CHESTER MD
21619-2528
US

V. Phone/Fax

Practice location:
  • Phone: 301-312-5243
  • Fax:
Mailing address:
  • Phone: 301-312-5243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: