Provider Demographics
NPI:1508276692
Name:GONZALES, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 WOODSTEAD CT
Mailing Address - Street 2:STE 208
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1480
Mailing Address - Country:US
Mailing Address - Phone:563-359-6786
Mailing Address - Fax:
Practice Address - Street 1:12380 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2511
Practice Address - Country:US
Practice Address - Phone:877-749-7428
Practice Address - Fax:512-628-3314
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018015039208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation