Provider Demographics
NPI:1801853106
Name:ALVAREZ DEL REAL, GONZALO (MD)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:ALVAREZ DEL REAL
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:PO BOX 415000 LBX 410604
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37241-0604
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP # 108
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4544
Practice Address - Fax:318-798-4557
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA311897207K00000X
TXM2536207K00000X
OK26175207R00000X, 207RA0201X
NMMD2011-0472207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMAAA1548OtherMEDICARE PTAN
TXI56892Medicare UPIN