1053404954 NPI number — JUAN H GONZALEZ MD PA

Table of content: (NPI 1053404954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053404954 NPI number — JUAN H GONZALEZ MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUAN H GONZALEZ MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1053404954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLMITO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5460 PAREDES LINE RD
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78526-9740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-554-7005
Provider Business Practice Location Address Fax Number:
956-554-3288
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
956-554-7005

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J9686 , 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: 092553902 . This is a "MEDICAID (THSTEPS)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 092553901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 133848100 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com