Healthcare Provider Details

I. General information

NPI: 1578641825
Provider Name (Legal Business Name): LUIS A. GONZALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 EAST 142ND STREET
BRONX NY
10454-1723
US

IV. Provider business mailing address

781 EAST 142ND STREET
BRONX NY
10454-1723
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-3060
  • Fax: 718-918-4469
Mailing address:
  • Phone: 718-993-1400
  • Fax: 718-993-0647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number190284-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number190284
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: