Basic Information
| Provider Information | |||||||||
| NPI: | 1417147596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 CALHOUN RD | ||||||||
| Address2: | ROOM 2104 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772042020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137432020 | ||||||||
| FaxNumber: | 7137430963 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 LUCAS DR | ||||||||
| Address2: | BLG 3 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752191804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145287354 | ||||||||
| FaxNumber: | 2145287387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6930TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 112409105 | 05 | TX | MEDICAID |