Provider Demographics
NPI:1295190551
Name:GONZALEZ, JUAN MARCELO JR
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MARCELO
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 DAVID RAY WAY
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7025
Mailing Address - Country:US
Mailing Address - Phone:915-474-6480
Mailing Address - Fax:
Practice Address - Street 1:1413 DAVID RAY WAY
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7025
Practice Address - Country:US
Practice Address - Phone:915-474-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health