Provider Demographics
NPI:1740506385
Name:GONZALES, JIMMY GAMEZ
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:GAMEZ
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 TREASURE HILLS BLVD
Mailing Address - Street 2:#3.144.05
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8736
Mailing Address - Country:US
Mailing Address - Phone:956-296-1437
Mailing Address - Fax:956-296-1326
Practice Address - Street 1:1000 E DOVE AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-3974
Practice Address - Country:US
Practice Address - Phone:956-362-3520
Practice Address - Fax:956-362-3529
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP3159207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313174003Medicaid
TX313174004OtherMEDICAID CSHCN PROGRAM
TX269670ZK0DMedicare PIN