Healthcare Provider Details

I. General information

NPI: 1295900629
Provider Name (Legal Business Name): LUCIEN GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2008
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

V. Phone/Fax

Practice location:
  • Phone: 919-966-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number2021-03413
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021-03413
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: