Basic Information
| Provider Information | |||||||||
| NPI: | 1356384622 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOT SPECIALISTS OF EL PASO | ||||||||
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| OtherOrganizationName: | DR. JUAN A . GONZALEZ D/B/A FOOT SPECIALISTS OF EL PASO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791716 | ||||||||
| FaxNumber: | 9157791754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N MESA ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799024046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155770744 | ||||||||
| FaxNumber: | 9155770271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 9155770744 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.M.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1282 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | Z00059AH7 | 05 | TX | MEDICAID |