Provider Demographics
NPI:1306464292
Name:GONZALEZ, CHRISTIAN (LICENSED DISPENSING)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LICENSED DISPENSING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 DR MARTIN LUTHER KING BLVD # G16
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-4809
Mailing Address - Country:US
Mailing Address - Phone:239-672-4368
Mailing Address - Fax:239-313-5259
Practice Address - Street 1:4135 DR MARTIN LUTHER KING BLVD # G16
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4809
Practice Address - Country:US
Practice Address - Phone:239-672-4368
Practice Address - Fax:239-313-5259
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7304156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician