Provider Demographics
NPI:1760628291
Name:GONZALEZ, JESUS CRUZ (HIS)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:CRUZ
Last Name:GONZALEZ
Suffix:
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 1:4714 GAVLICK FARM
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1328
Mailing Address - Country:US
Mailing Address - Phone:210-251-6233
Mailing Address - Fax:210-201-8107
Practice Address - Street 1:4714 GAVLICK FARM
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1328
Practice Address - Country:US
Practice Address - Phone:210-251-6233
Practice Address - Fax:210-201-8107
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80311237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80311OtherHEARING AID FITTER AND DISPENSOR