MEDICARE: DR. FLORDELIZ GRACE GONZALES O.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	33651	CA

General Provider Information

NPI Number	:	1346775319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FLORDELIZ GRACE GONZALES O.D

Provider Business Mailing Address
First Line	:	5460 WHITE OAK AVE UNIT C339
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-4561
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5460 WHITE OAK AVE UNIT C339
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-4561
Country	:	US
Telephone Number	:	818-854-2526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	04/26/2017

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