Provider Demographics
NPI:1144345984
Name:GONZALEZ, LUISA S
Entity type:Individual
Prefix:DR
First Name:LUISA
Middle Name:S
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 ROUTE 11 APT. 3C
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-4101
Practice Address - Country:US
Practice Address - Phone:607-724-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP465922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP46592Medicaid
NYP46592Medicaid