Provider Demographics
NPI:1033269279
Name:GONZALEZ, WALDO (MD)
Entity Type:Individual
Prefix:
First Name:WALDO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150507
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-0507
Mailing Address - Country:US
Mailing Address - Phone:936-634-8216
Mailing Address - Fax:936-634-8723
Practice Address - Street 1:302 MEDICAL PARK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3148
Practice Address - Country:US
Practice Address - Phone:936-634-8216
Practice Address - Fax:936-634-8723
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2889208600000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138116203Medicaid
TXE327OtherBLUE CROSS
TX138116203Medicaid
TX00E327Medicare ID - Type Unspecified