Provider Demographics
NPI:1417289281
Name:GONZALEZ, CONSUELO CAMARILLO (LICAC)
Entity Type:Individual
Prefix:DR
First Name:CONSUELO
Middle Name:CAMARILLO
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:DR
Other - First Name:CONSUELO
Other - Middle Name:
Other - Last Name:CAMARILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:236 LINDBERG AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-2920
Mailing Address - Country:US
Mailing Address - Phone:956-668-0655
Mailing Address - Fax:956-668-0943
Practice Address - Street 1:236 LINDBERG AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2920
Practice Address - Country:US
Practice Address - Phone:956-668-0655
Practice Address - Fax:956-668-0943
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX538582171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102886OtherNCCAOM