Healthcare Provider Details

I. General information

NPI: 1659370963
Provider Name (Legal Business Name): JUAN CARLOS GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUAN CARLOS GONZALEZ M.D.

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 BABCOCK RD SUITE 101
SAN ANTONIO TX
78229-4708
US

IV. Provider business mailing address

PO BOX 291096
SAN ANTONIO TX
78229-1696
US

V. Phone/Fax

Practice location:
  • Phone: 210-200-8798
  • Fax: 210-247-9385
Mailing address:
  • Phone: 210-200-8798
  • Fax: 210-247-9385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL7397
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: