Basic Information
| Provider Information | |||||||||
| NPI: | 1043266869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846170 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022846170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241058 | ||||||||
| FaxNumber: | 8025241289 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | ST ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241058 | ||||||||
| FaxNumber: | 8025241289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 05/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 042-0009728 | VT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0VN1883 | 05 | VT | MEDICAID | 300123221 | 01 | VT | RAILROAD MEDICARE | OTHER |