Provider Demographics
NPI:1053404954
Name:JUAN H GONZALEZ MD PA
Entity type:Organization
Organization Name:JUAN H GONZALEZ MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-554-7005
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:OLMITO
Mailing Address - State:TX
Mailing Address - Zip Code:78575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5460 PAREDES LINE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-9740
Practice Address - Country:US
Practice Address - Phone:956-554-7005
Practice Address - Fax:956-554-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092553902OtherMEDICAID (THSTEPS)
TX092553901Medicaid
TX133848100OtherFIRST CARE
TX133848100OtherFIRST CARE