Provider Demographics
NPI:1558302976
Name:LIEVANO, GONZALO (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:LIEVANO
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 1:1307 8TH AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-912-8040
Mailing Address - Fax:817-912-8049
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:STE 306
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-912-8040
Practice Address - Fax:817-912-8049
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5024208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155486702Medicaid
TX8S3521OtherBCBS
TX155486703Medicaid
TX8D8817Medicare PIN
TX155486702Medicaid
TX155486703Medicaid