Healthcare Provider Details

I. General information

NPI: 1184894701
Provider Name (Legal Business Name): BERNICE GONZALEZ, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 05/08/2013
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 STREET SUITE 100
SAN ANTONIO TX
78215
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 Code261Q00000X
TaxonomyClinic/Center
License NumberJ6466
License Number StateTX

VIII. Authorized Official

Name: DR. BERNICE GONZALEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 210-595-1019