=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699718098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GONZALO T CHUA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 02/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 N SENATE BLVD ROOM 1204A
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-962-6793
-----------------------------------------------------
Fax | 317-962-8281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 N SENATE AVE STE EF100
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-715-6402
-----------------------------------------------------
Fax | 317-715-6415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0904X
-----------------------------------------------------
Taxonomy Name | Nuclear Radiology Physician
-----------------------------------------------------
License Number | 01021628
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 01021628
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------