Provider Demographics
NPI:1104053602
Name:GONZALEZ, MARISSA RENEE (MD)
Entity type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:RENEE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:220 W HILLSIDE RD
Mailing Address - Street 2:STE 4A
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6903
Mailing Address - Country:US
Mailing Address - Phone:956-726-6937
Mailing Address - Fax:888-972-3859
Practice Address - Street 1:220 W HILLSIDE RD
Practice Address - Street 2:STE 4A
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041
Practice Address - Country:US
Practice Address - Phone:956-726-6937
Practice Address - Fax:866-916-2013
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2021-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXP4170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP4170OtherLICIENSE