Healthcare Provider Details

I. General information

NPI: 1700265873
Provider Name (Legal Business Name): GONZALO A AILLON MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S ZANG BLVD SUITE 802
DALLAS TX
75208-6643
US

IV. Provider business mailing address

400 S ZANG BLVD SUITE 802
DALLAS TX
75208-6643
US

V. Phone/Fax

Practice location:
  • Phone: 214-943-9406
  • Fax: 214-944-5511
Mailing address:
  • Phone: 214-943-9406
  • Fax: 214-944-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberD-7730
License Number StateTX

VIII. Authorized Official

Name: DR. GONZALO A AILLON
Title or Position: OWNER
Credential: M.D.
Phone: 214-943-9406