Provider Demographics
NPI:1962698431
Name:MICHELLE GONZALEZ OD PA
Entity type:Organization
Organization Name:MICHELLE GONZALEZ OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-484-0700
Mailing Address - Street 1:4300 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-1918
Mailing Address - Country:US
Mailing Address - Phone:954-484-0700
Mailing Address - Fax:954-484-0705
Practice Address - Street 1:4300 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-1918
Practice Address - Country:US
Practice Address - Phone:954-484-0700
Practice Address - Fax:954-484-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty