Provider Demographics
NPI:1194954271
Name:VENEGAS MEDICAL FOUNDATION
Entity type:Organization
Organization Name:VENEGAS MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:VENEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-942-3100
Mailing Address - Street 1:8 MEDICAL PARKWAY
Mailing Address - Street 2:PLAZA 2 SUITE 310
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234
Mailing Address - Country:US
Mailing Address - Phone:214-333-2366
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL PARKWAY
Practice Address - Street 2:PLAZA 2 SUITE 310
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234
Practice Address - Country:US
Practice Address - Phone:214-333-2366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
TXH6974207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2076721-01Medicaid