Healthcare Provider Details

I. General information

NPI: 1710216130
Provider Name (Legal Business Name): MARCO ANTONIO GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 REDD RD
EL PASO TX
79911-3026
US

IV. Provider business mailing address

1480 REDD RD
EL PASO TX
79911-3026
US

V. Phone/Fax

Practice location:
  • Phone: 915-600-2639
  • Fax: 915-702-0023
Mailing address:
  • Phone: 915-600-2639
  • Fax: 915-702-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberP2248
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberP2248
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: