Provider Demographics
NPI:1578861712
Name:GONZALES, JOHN IV (HIS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GONZALES
Suffix:IV
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4307 FAIR HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7339
Mailing Address - Country:US
Mailing Address - Phone:417-631-2522
Mailing Address - Fax:
Practice Address - Street 1:1902 W 19TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1287
Practice Address - Country:US
Practice Address - Phone:417-631-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-12
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010035283237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist