Provider Demographics
NPI:1235318361
Name:GONZALES, ERNESTINE GRACE (RD,LD,CDE)
Entity Type:Individual
Prefix:MS
First Name:ERNESTINE
Middle Name:GRACE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PARK TEN BLVD STE 150-S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4211
Mailing Address - Country:US
Mailing Address - Phone:210-733-0200
Mailing Address - Fax:210-733-6202
Practice Address - Street 1:6800 PARK TEN BLVD STE 150-S
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-4211
Practice Address - Country:US
Practice Address - Phone:210-733-0200
Practice Address - Fax:210-733-6202
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT00925133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00357UMedicare UPIN