Basic Information
| Provider Information | |||||||||
| NPI: | 1083140917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | DIEGO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722653 | ||||||||
| FaxNumber: | 4097725462 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 W ALTON GLOOR BLVD | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785203506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565445700 | ||||||||
| FaxNumber: | 9563509573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10060869 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | S4307 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.