Provider Demographics
NPI:1245266170
Name:GONZALEZ, JUAN ALBERTO (DPM)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ALBERTO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:5959 GATEWAY BLVD W
Mailing Address - Street 2:STE 120
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3331
Mailing Address - Country:US
Mailing Address - Phone:915-779-1716
Mailing Address - Fax:915-779-1754
Practice Address - Street 1:1501 N MESA ST
Practice Address - Street 2:SUITE 104
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4046
Practice Address - Country:US
Practice Address - Phone:915-577-0744
Practice Address - Fax:915-577-0271
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1282213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109394001Medicaid
TX5942270001Medicare PIN
U55679Medicare UPIN
TX109394001Medicaid