Provider Demographics
NPI:1962956771
Name:GONZALEZ, MARTHA A (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3641 MATTOX ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-1307
Mailing Address - Country:US
Mailing Address - Phone:915-532-6280
Mailing Address - Fax:
Practice Address - Street 1:3641 MATTOX ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1307
Practice Address - Country:US
Practice Address - Phone:915-532-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80042133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic