Provider Demographics
NPI:1831176635
Name:GONZALEZ, DORA L (MD)
Entity type:Individual
Prefix:DR
First Name:DORA
Middle Name:L
Last Name:GONZALEZ
Suffix:
Gender:F
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:PO BOX 204237
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-4237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 HAYS ST
Practice Address - Street 2:B
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-3207
Practice Address - Country:US
Practice Address - Phone:512-324-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9485207Q00000X
WAMD60340257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102686601Medicaid
327159YSH2OtherPTAN
TXB87835Medicare UPIN