Provider Demographics
NPI:1437196276
Name:OMAR GONZALEZ, M.D., P.A.
Entity Type:Organization
Organization Name:OMAR GONZALEZ, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-253-1757
Mailing Address - Street 1:PO BOX 71449
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79917-1449
Mailing Address - Country:US
Mailing Address - Phone:915-222-8275
Mailing Address - Fax:915-544-5696
Practice Address - Street 1:1715 SAUL KLEINFIELD BLDG A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-222-8275
Practice Address - Fax:915-544-5696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150280902Medicaid
TXDA1509Medicare PIN
TX150280902Medicaid