MEDICARE: DR. G CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	P4959	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588193452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. G CLINIC, PLLC

Provider Business Mailing Address
First Line	:	1032 VALLE VISTA LN
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-4050
Country	:	US
Telephone Number	:	575-636-4877
Fax Number	:

Provider Business Practice Location Address
First Line	:	4913 RUFE SNOW DR STE 102
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-7856
Country	:	US
Telephone Number	:	275-636-4877
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARIO G GONZALEZ
Credential	:	MD
Telephone Number	:	575-636-4877

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	06/05/2017

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