Provider Demographics
NPI:1962497594
Name:GONZALEZ, GUS ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:GUS
Middle Name:ANTHONY
Last Name:GONZALEZ
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 1:701 FALLING SKY DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-0808
Mailing Address - Country:US
Mailing Address - Phone:417-544-4147
Mailing Address - Fax:
Practice Address - Street 1:701 FALLING SKY DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-0808
Practice Address - Country:US
Practice Address - Phone:417-544-4147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6151207RX0202X
MO2014027664207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100216400DMedicaid
TX1886756-01Medicaid
MO200016575Medicaid
TX1886756-03Medicaid
MO1962497594Medicaid
OK100216400DMedicaid