MEDICARE: JOSE MAURICIO GONZALES MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	22265	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144221615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE MAURICIO GONZALES MD

Provider Business Mailing Address
First Line	:	2509 MAPLEWOOD DR
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663
Country	:	US
Telephone Number	:	337-625-0341
Fax Number	:	337-625-0347

Provider Business Practice Location Address
First Line	:	2509 MAPLEWOOD DR.
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663
Country	:	US
Telephone Number	:	337-625-0341
Fax Number	:	337-625-0347

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	05/26/2020

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