Provider Demographics
NPI:1992160550
Name:GONZALEZ, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:2030 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CARRIZO SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78834-2028
Mailing Address - Country:US
Mailing Address - Phone:830-876-9109
Mailing Address - Fax:830-876-9156
Practice Address - Street 1:2030 N 1ST ST
Practice Address - Street 2:
Practice Address - City:CARRIZO SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78834-2028
Practice Address - Country:US
Practice Address - Phone:830-876-9109
Practice Address - Fax:830-876-9156
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist