Provider Demographics
NPI:1053591024
Name:GONZALEZ, LUIS FERNANDO (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:FERNANDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST # 6115E
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:410-955-2438
Practice Address - Fax:443-287-0339
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437666207T00000X
NJ25MA08778100207T00000X
MDD91181207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102366468Medicaid
NJ0205613Medicaid
PA168498Medicare PIN
PA102366468Medicaid