=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134866221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ANTHONY GONZALEZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2022
-----------------------------------------------------
Last Update Date | 10/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 N. BEN WILSON ST. SUITE 100
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-305-6500
-----------------------------------------------------
Fax | 361-305-6501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2810 N BEN WILSON ST STE 100
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-5641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-305-6500
-----------------------------------------------------
Fax | 361-305-6501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | U6960
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------