Provider Demographics
NPI:1417147596
Name:GONZALES, MARCUS B (OD)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:B
Last Name:GONZALES
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:4901 CALHOUN RD
Mailing Address - Street 2:ROOM 2104
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77204-2020
Mailing Address - Country:US
Mailing Address - Phone:713-743-2020
Mailing Address - Fax:713-743-0963
Practice Address - Street 1:2525 LUCAS DR
Practice Address - Street 2:BLG 3
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-1804
Practice Address - Country:US
Practice Address - Phone:214-528-7354
Practice Address - Fax:214-528-7387
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2015-09-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX6930TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112409105Medicaid
TX00E63GMedicare UPIN
TXTXB109377Medicare UPIN