Provider Demographics
NPI:1124138946
Name:AILLON, GONZALO A (MD)
Entity type:Individual
Prefix:
First Name:GONZALO
Middle Name:A
Last Name:AILLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S ZANG BLVD SUITE 802
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208
Mailing Address - Country:US
Mailing Address - Phone:214-943-9406
Mailing Address - Fax:214-943-9408
Practice Address - Street 1:400 S ZANG BLVD SUITE 802
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:214-943-9406
Practice Address - Fax:214-943-9408
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD77302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C12640Medicare UPIN
00R167Medicare ID - Type Unspecified