Provider Demographics
NPI:1710282041
Name:GONZALES, MARK JEROME V (PT)
Entity Type:Individual
Prefix:
First Name:MARK JEROME
Middle Name:V
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10060 MCCOMBS ST H
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-4245
Mailing Address - Country:US
Mailing Address - Phone:915-408-0699
Mailing Address - Fax:915-503-2297
Practice Address - Street 1:10060 MCCOMBS ST H
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4245
Practice Address - Country:US
Practice Address - Phone:915-408-0699
Practice Address - Fax:915-503-2297
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1123313225100000X
TX111483225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX669570000OtherTEXAS BOARD OF PHYSICAL AND OCCUPATIONAL THERAPY