Basic Information
| Provider Information | |||||||||
| NPI: | 1679660260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | ALBERTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAZQUEZ | ||||||||
| OtherFirstName: | LUIS | ||||||||
| OtherMiddleName: | ALBERTO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646253 | ||||||||
| FaxNumber: | 5173646208 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 LAKE CITY HWY | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465803942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742694144 | ||||||||
| FaxNumber: | 5742682281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301054514 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 01080663A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4288420 | 05 | MI | MEDICAID | 1603304641 | 01 | MI | BCBS INDIVIDUAL PIN | OTHER | 2868162 | 05 | MI | MEDICAID |