Healthcare Provider Details

I. General information

NPI: 1346250255
Provider Name (Legal Business Name): JUAN CARLOS GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 MONTOPOLIS DR
AUSTIN TX
78741-6411
US

IV. Provider business mailing address

6102 SHADOW MOUNTAIN DR
AUSTIN TX
78731-4161
US

V. Phone/Fax

Practice location:
  • Phone: 512-389-6771
  • Fax: 512-389-6544
Mailing address:
  • Phone: 512-389-6771
  • Fax: 512-389-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberH9958
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: