Provider Demographics
NPI:1558313643
Name:PETER C. W. GONZALES, M.D., P.A.
Entity type:Organization
Organization Name:PETER C. W. GONZALES, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CHAN WONG
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-870-5500
Mailing Address - Street 1:3204 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-4453
Mailing Address - Country:US
Mailing Address - Phone:972-870-5500
Mailing Address - Fax:972-870-5504
Practice Address - Street 1:3204 N MACARTHUR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-4453
Practice Address - Country:US
Practice Address - Phone:972-870-5500
Practice Address - Fax:972-870-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0053BFOtherBLUE CROSS BLUE SHIELD
00720XMedicare ID - Type Unspecified