1538424445 NPI number — JESUS R GONZALEZ JR. PA

Table of content: JESUS R GONZALEZ JR. PA (NPI 1538424445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538424445 NPI number — JESUS R GONZALEZ JR. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
JESUS
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GONZALEZ
Provider Other First Name:
JESSE
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1538424445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 S 1ST ST STE 600
Provider Second Line Business Mailing Address:
MCALLEN
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78503-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-631-6136
Provider Business Mailing Address Fax Number:
956-631-6136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S 1ST ST STE 600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78503-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-631-6136
Provider Business Practice Location Address Fax Number:
956-631-6136
Provider Enumeration Date:
07/06/2012

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: 363A00000X , with the licence number:  PA07786 , 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: 335076101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA07786 . This is a "TEXAS MEDICAL BOARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".