Basic Information
| Provider Information | |||||||||
| NPI: | 1326029869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | DAGOBERTO | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7109 BARTLETT AVE SUTE 101 | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567175775 | ||||||||
| FaxNumber: | 9567175875 | ||||||||
| Practice Location | |||||||||
| Address1: | 7109 BARTLETT AVE SUTE 101 | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567175775 | ||||||||
| FaxNumber: | 9567175875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | K3902 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1654683-01 | 05 | TX | MEDICAID | 8M7440 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |