1164418711 NPI number — DR. MARK S GONZALEZ MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164418711 NPI number — DR. MARK S GONZALEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164418711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78502-4449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-362-2171
Provider Business Mailing Address Fax Number:
956-661-2204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE #A
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78503-1345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-682-1888
Provider Business Practice Location Address Fax Number:
956-661-2204
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  H0391 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 143824402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143824403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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