Provider Demographics
NPI:1073567392
Name:GONZALEZ, JORGE ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ANTONIO
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 1:5010 E 68TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3341
Mailing Address - Country:US
Mailing Address - Phone:918-236-5881
Mailing Address - Fax:918-236-5885
Practice Address - Street 1:5010 E 68TH ST STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3341
Practice Address - Country:US
Practice Address - Phone:918-236-5881
Practice Address - Fax:918-236-5885
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK195582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100020260CMedicaid
F34063Medicare UPIN
OK100020260CMedicaid