Provider Demographics
NPI:1730112988
Name:VENEGAS, GONZALO (MD)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:VENEGAS
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 1:1135 N BISHOP AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4114
Mailing Address - Country:US
Mailing Address - Phone:214-942-3100
Mailing Address - Fax:214-942-8030
Practice Address - Street 1:1135 N BISHOP AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4114
Practice Address - Country:US
Practice Address - Phone:214-942-3100
Practice Address - Fax:214-942-8030
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6974207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097866001Medicaid
TXE77098Medicare UPIN
TX097866001Medicaid