Basic Information
| Provider Information | |||||||||
| NPI: | 1770962888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | MCHE-QD (CREDS) | ||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109162460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | MCHE-QD (CREDS) | ||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109162460 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101261696 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 0101261696 | VA | N | Allopathic & Osteopathic Physicians | General Practice | 207RH0003X | 0101261696 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.