Provider Demographics
NPI:1144221615
Name:GONZALES, JOSE MAURICIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MAURICIO
Last Name:GONZALES
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 1:2509 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663
Mailing Address - Country:US
Mailing Address - Phone:337-625-0341
Mailing Address - Fax:337-625-0347
Practice Address - Street 1:2509 MAPLEWOOD DR.
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663
Practice Address - Country:US
Practice Address - Phone:337-625-0341
Practice Address - Fax:337-625-0347
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1682969Medicaid
5W816Medicare ID - Type Unspecified
G26860Medicare UPIN