MEDICARE: DR. MARCO ANTONIO GONZALEZ MD

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	2086S0122X	Plastic and Reconstructive Surgery Physician	P2248	TX
2	208200000X	Plastic Surgery Physician	P2248	TX

General Provider Information

NPI Number	:	1710216130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCO ANTONIO GONZALEZ MD

Provider Business Mailing Address
First Line	:	1480 REDD RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79911-3026
Country	:	US
Telephone Number	:	915-600-2639
Fax Number	:	915-702-0023

Provider Business Practice Location Address
First Line	:	1480 REDD RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79911-3026
Country	:	US
Telephone Number	:	915-600-2639
Fax Number	:	915-702-0023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2009
Last Update Date	:	12/22/2021

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