Provider Demographics
NPI:1699178756
Name:GONZALES, MARK JOSEPH
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16874 FM 463
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-4515
Mailing Address - Country:US
Mailing Address - Phone:210-239-6873
Mailing Address - Fax:
Practice Address - Street 1:16874 FM 463
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-4515
Practice Address - Country:US
Practice Address - Phone:210-239-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00742246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant