Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | 0101242453 | VA |
N | 207RI0200X | Infectious Disease | T2172 | TX |
NPI | 1073781142 |
---|---|
Provider Name | Antonio Victor Prudente Gonzalez |
First Address | Frisco, TX 75035-0526 |
Second Address | Richmond, VA 23229-4938 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2008 |
Last Update Date | 13/08/2021 |