Healthcare Provider Details

I. General information

NPI: 1184622904
Provider Name (Legal Business Name): BERNICE GONZALEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 11/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 BROADWAY ST SUITE 100
SAN ANTONIO TX
78215-1004
US

IV. Provider business mailing address

2520 BROADWAY ST SUITE 100
SAN ANTONIO TX
78215-1004
US

V. Phone/Fax

Practice location:
  • Phone: 210-595-1019
  • Fax: 210-251-3194
Mailing address:
  • Phone: 210-595-1019
  • Fax: 210-251-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ6466
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: