Provider Demographics
NPI:1780628271
Name:GONZALEZ, DANIEL DAVID (PT, OCS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DAVID
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LIVINGSTON LOOP
Mailing Address - Street 2:STE. B-1
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9747
Mailing Address - Country:US
Mailing Address - Phone:575-587-7061
Mailing Address - Fax:915-493-8264
Practice Address - Street 1:103 LIVINGSTON LOOP
Practice Address - Street 2:STE. B-1
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9747
Practice Address - Country:US
Practice Address - Phone:575-587-7061
Practice Address - Fax:915-493-8264
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072890225100000X
NM2431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609999Medicare PIN