Provider Demographics
NPI:1326252560
Name:GONZALES, RICHARD H (CP, LPO)
Entity Type:Individual
Prefix:PROF
First Name:RICHARD
Middle Name:H
Last Name:GONZALES
Suffix:
Gender:M
Credentials:CP, LPO
Other - Prefix:PROF
Other - First Name:RICCARDO
Other - Middle Name:H
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CP, LPO
Mailing Address - Street 1:407 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6512
Mailing Address - Country:US
Mailing Address - Phone:903-241-0675
Mailing Address - Fax:903-234-0248
Practice Address - Street 1:407 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6512
Practice Address - Country:US
Practice Address - Phone:903-241-0675
Practice Address - Fax:903-234-0248
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX131222Z00000X, 224P00000X
TXCP001022224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX69606542OtherBLUE CROSS BLUE SHIELD