Healthcare Provider Details

I. General information

NPI: 1568546521
Provider Name (Legal Business Name): EDMOND T. GONZALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST
HOUSTON TX
77030-2316
US

IV. Provider business mailing address

2 GREENWAY PLZ SUITE 900
HOUSTON TX
77046-0297
US

V. Phone/Fax

Practice location:
  • Phone: 832-822-3160
  • Fax: 832-825-3159
Mailing address:
  • Phone: 713-798-1750
  • Fax: 713-798-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberE3181
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: