Healthcare Provider Details

I. General information

NPI: 1487973319
Provider Name (Legal Business Name): ANDREW BALDOMERO GONZALEZ OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 CALIFORNIA AVE SUITE 103
BAKERSFIELD CA
93304-1383
US

IV. Provider business mailing address

1603 CALIFORNIA AVE SUITE 103
BAKERSFIELD CA
93304-1383
US

V. Phone/Fax

Practice location:
  • Phone: 661-204-1985
  • Fax: 661-670-5277
Mailing address:
  • Phone: 661-204-1985
  • Fax: 661-670-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberSL 6043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: