MEDICARE: IVETTE H GONZALEZ 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	152WP0200X	Pediatric Optometrist	PENDING	FL

General Provider Information

NPI Number	:	1588827141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVETTE H GONZALEZ O.D.

Provider Business Mailing Address
First Line	:	777 E MERRITT ISLAND CSWY
Second Line	:	STE F14
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3576
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 E MERRITT ISLAND CSWY
Second Line	:	STE F14
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3576
Country	:	US
Telephone Number	:	321-454-4800
Fax Number	:	321-454-2019

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

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	12/09/2015

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