Healthcare Provider Details

I. General information

NPI: 1154636686
Provider Name (Legal Business Name): LUIS C GONZALEZ MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 INTERSTATE PKWY
BRADFORD PA
16701-1041
US

IV. Provider business mailing address

181 INTERSTATE PKWY
BRADFORD PA
16701-1041
US

V. Phone/Fax

Practice location:
  • Phone: 814-362-4345
  • Fax: 814-362-1178
Mailing address:
  • Phone: 814-362-4345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD0549041
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number363AS0400X
License Number StatePA

VIII. Authorized Official

Name: DR. LUIS CARLOS GONZALEZ
Title or Position: OWNER
Credential: MD
Phone: 814-362-4345