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General NPI Number Information
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NPI Number | 1164425997
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Entity Type | Individual
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Provider Name | LUISITO C. GONZALES M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/24/2005
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Last Update Date | 03/16/2016
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Provider Practice Location Address
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Address Line | 303 S NAPPANEE ST SUITE A
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City | ELKHART
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State | IN
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Zip | 46514-2066
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Country | US
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Telephone | 574-296-3338
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Fax | 574-296-3332
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Provider Business Mailing Address
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Address Line | 710 N NILES AVE
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City | SOUTH BEND
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State | IN
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Zip | 46617-1924
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Country | US
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Telephone | 574-647-1610
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 01046919A
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License Number State | IN
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