Healthcare Provider Details

I. General information

NPI: 1629206867
Provider Name (Legal Business Name): OLGA LUCIA GONZALEZ DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14201 PARK CENTER DR STE 410
LAUREL MD
20707-5251
US

IV. Provider business mailing address

14201 PARK CENTER DR STE 410
LAUREL MD
20707-5251
US

V. Phone/Fax

Practice location:
  • Phone: 301-498-0340
  • Fax: 301-618-0594
Mailing address:
  • Phone: 301-498-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC006115
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: