Provider Demographics
NPI:1386704781
Name:GAGO, LUIS C (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:C
Last Name:GAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:850 W NORTH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3196
Mailing Address - Country:US
Mailing Address - Phone:877-852-8463
Mailing Address - Fax:571-817-0144
Practice Address - Street 1:2350 E STADIUM BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4889
Practice Address - Country:US
Practice Address - Phone:877-852-8463
Practice Address - Fax:734-994-6283
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301076027207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI467549710Medicaid
LG076027OtherCOMMERCIAL-COMMERCIAL NUMBER
MI180H149970OtherBCBSM
LG076027OtherCHAMPUS-CHAMPUS
MI1386704781Medicaid
180H262240OtherBLUE CROSS-BLUE CROSS
MI0H14997025Medicare PIN
180H262240OtherBLUE CROSS-BLUE CROSS
MI0C84631034Medicare PIN
LG076027OtherCHAMPUS-CHAMPUS