Healthcare Provider Details

I. General information

NPI: 1588827141
Provider Name (Legal Business Name): IVETTE H GONZALEZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E MERRITT ISLAND CSWY STE F14
MERRITT ISLAND FL
32952-3576
US

IV. Provider business mailing address

777 E MERRITT ISLAND CSWY STE F14
MERRITT ISLAND FL
32952-3576
US

V. Phone/Fax

Practice location:
  • Phone: 321-454-4800
  • Fax: 321-454-2019
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberPENDING
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: