1063412351 NPI number — ANNA M GONZALES M.D.

Table of content: ANNA M GONZALES M.D. (NPI 1063412351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063412351 NPI number — ANNA M GONZALES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
ANNA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1063412351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130894
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77393-0894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-321-0033
Provider Business Mailing Address Fax Number:
936-321-0032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 VISION PARK BLVD
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
SHENANDOAH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-321-0033
Provider Business Practice Location Address Fax Number:
936-321-0032
Provider Enumeration Date:
07/28/2005

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: 207RG0100X , with the licence number:  L3977 , 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: 158075501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 158075502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2986654 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1664695 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 191459 . This is a "AMERICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7046365 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 84442Y . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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