Provider Demographics
NPI:1437490281
Name:GONZALEZ, DIANA LAURA (R,PH)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LAURA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11551 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1343
Mailing Address - Country:US
Mailing Address - Phone:210-340-7786
Mailing Address - Fax:210-308-0138
Practice Address - Street 1:11551 WEST AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1343
Practice Address - Country:US
Practice Address - Phone:210-340-7786
Practice Address - Fax:210-308-0138
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist