Basic Information
Provider Information | |||||||||
NPI: | 1740506385 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALES | ||||||||
FirstName: | JIMMY | ||||||||
MiddleName: | GAMEZ | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2102 TREASURE HILLS BLVD | ||||||||
Address2: | #3.144.05 | ||||||||
City: | HARLINGEN | ||||||||
State: | TX | ||||||||
PostalCode: | 785508736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9562961437 | ||||||||
FaxNumber: | 9562961326 | ||||||||
Practice Location | |||||||||
Address1: | 1000 E DOVE AVE | ||||||||
Address2: |   | ||||||||
City: | MCALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 785043974 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9563623520 | ||||||||
FaxNumber: | 9563623529 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2010 | ||||||||
LastUpdateDate: | 05/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207QS0010X | P3159 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 313174003 | 05 | TX |   | MEDICAID | 313174004 | 01 | TX | MEDICAID CSHCN PROGRAM | OTHER |