Provider Demographics
NPI:1124004841
Name:GONZALES, MAE P (MD)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:P
Last Name:GONZALES
Suffix:
Gender:F
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7920 ELMBROOK DR STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4933
Practice Address - Country:US
Practice Address - Phone:214-590-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127671930Medicaid
TX127671934Medicaid
TX127671931Medicaid
TX127671915Medicaid
TX127671917Medicaid
TX127671918Medicaid
TX8743J8OtherBLUE CROSS BLUE SHIELD
TX127671927Medicaid
TX127671933Medicaid
TX127671921Medicaid
TX127671924Medicaid
TX127671925Medicaid
TX127671932Medicaid
TX127671904Medicaid
TX127671909Medicaid
TX127671911Medicaid
TX127671936Medicaid
TX080183432OtherRAILROAD MEDICARE
TX127671914Medicaid
TX127671923Medicaid
TX127671926Medicaid
TX127671913Medicaid
TX127671920Medicaid
TX127671928Medicaid
TX127671926Medicaid
TX127671932Medicaid