Healthcare Provider Details

I. General information

NPI: 1528605284
Provider Name (Legal Business Name): ELISA MARIA GONZALES MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10718 POTRANCO RD
SAN ANTONIO TX
78251-3312
US

IV. Provider business mailing address

646 S FLORES ST
SAN ANTONIO TX
78204-1219
US

V. Phone/Fax

Practice location:
  • Phone: 855-481-1149
  • Fax:
Mailing address:
  • Phone: 855-481-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDT83501
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: