Provider Demographics
NPI:1104335249
Name:GONZALEZ, MARIO ATILIO
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:ATILIO
Last Name:GONZALEZ
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 1:3710 ARANDA FLDS
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3543
Mailing Address - Country:US
Mailing Address - Phone:210-995-3974
Mailing Address - Fax:
Practice Address - Street 1:3710 ARANDA FLDS
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-3543
Practice Address - Country:US
Practice Address - Phone:210-995-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41606930347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle