=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114263332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MA.LOURDES CASTILLO GONZALES,MD,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2012
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17013 HILLSIDE AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-472-1710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94 VILLAGE AVE
-----------------------------------------------------
City | ELMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11003-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-472-1710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEDICAL DIRECTOR
-----------------------------------------------------
Name | MA.LOURDES C GONZALES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 516-472-1710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number | 243713
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 243713
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------