Provider Demographics
NPI:1124094107
Name:GONZALEZ, JORGE G (OD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:G
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:797 WOODLAND DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-5132
Mailing Address - Country:US
Mailing Address - Phone:276-694-7126
Mailing Address - Fax:276-694-7449
Practice Address - Street 1:797 WOODLAND DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:276-694-7126
Practice Address - Fax:276-694-7449
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0601800089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009230611Medicaid
VA009230611Medicaid
VA410001211Medicare PIN
VAC06690Medicare PIN
VAU79176Medicare UPIN