Provider Demographics
NPI:1528707254
Name:GONZALEZ, MARISSA ALEJANDRA (DO)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ALEJANDRA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 CANYON BRK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-2603
Mailing Address - Country:US
Mailing Address - Phone:956-763-2996
Mailing Address - Fax:
Practice Address - Street 1:4301 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209
Practice Address - Country:US
Practice Address - Phone:210-829-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program