Provider Demographics
NPI:1609810175
Name:GONZALES, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:1100 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4813
Mailing Address - Country:US
Mailing Address - Phone:210-271-3204
Mailing Address - Fax:210-222-2761
Practice Address - Street 1:1100 MCCULLOUGH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4813
Practice Address - Country:US
Practice Address - Phone:210-271-3204
Practice Address - Fax:210-222-2761
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4101207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CU331OtherBCBS
TXP00325412OtherRAILROAD MEDICARE
TXP00948200OtherRAILROAD
TX8V3734OtherBCBS
TX181381803Medicaid
TXP00325412OtherRAILROAD MEDICARE
TXTXB126125Medicare PIN
I55797Medicare UPIN
TX181381802Medicaid
TX8CK576OtherBCBS
TXP00948200OtherRAILROAD
TXTXB108111Medicare PIN