1780717595 NPI number — DR. ANNIKA MARIE GONZALEZ MD

Table of content: DR. ANNIKA MARIE GONZALEZ MD (NPI 1780717595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780717595 NPI number — DR. ANNIKA MARIE GONZALEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
ANNIKA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780717595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11130 CHRISTUS HILLS
Provider Second Line Business Mailing Address:
2ND FLOOR, SUITE 201
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78251-3584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-703-9001
Provider Business Mailing Address Fax Number:
210-703-9155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11130 CHRISTUS HILLS
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-703-7001
Provider Business Practice Location Address Fax Number:
210-703-9155
Provider Enumeration Date:
03/13/2007

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: 207Q00000X , with the licence number:  M6150 , 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: 1937781-05 . This is a "MEDICAID CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1937781-04 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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