Provider Demographics
NPI:1457598427
Name:GONZALES, ANGIE T (CPO)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:T
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1511
Mailing Address - Country:US
Mailing Address - Phone:214-827-2021
Mailing Address - Fax:214-823-5462
Practice Address - Street 1:3910 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1511
Practice Address - Country:US
Practice Address - Phone:214-827-2021
Practice Address - Fax:214-823-5462
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLPO 1271224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist