Healthcare Provider Details

I. General information

NPI: 1902395601
Provider Name (Legal Business Name): LUIS FERNANDO GONZALEZ MOSQUERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MILITARY HEIGHTS PL
ROSWELL NM
88201-6407
US

IV. Provider business mailing address

2800 W GRAND BLVD
DETROIT MI
48202-2610
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-9110
  • Fax: 575-627-9535
Mailing address:
  • Phone: 888-777-4167
  • Fax: 313-916-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351048906
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD2025-0074
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: