Provider Demographics
NPI:1518948728
Name:GONZALES, JAMES D (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
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 1:400 BORDERS CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9425
Mailing Address - Country:US
Mailing Address - Phone:817-481-2012
Mailing Address - Fax:817-355-4511
Practice Address - Street 1:515 W SOUTHLAKE BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6172
Practice Address - Country:US
Practice Address - Phone:817-540-3121
Practice Address - Fax:817-355-4511
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8134174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85T503Medicare ID - Type Unspecified
TXE37347Medicare UPIN