Healthcare Provider Details

I. General information

NPI: 1871750133
Provider Name (Legal Business Name): ENRIQUE GONZALEZ-BERNARD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6178 OXON HILL RD STE 100
OXON HILL MD
20745-3161
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 301-839-5555
  • Fax: 301-839-1867
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-795-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002572
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002532
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberDA 2084
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberDA 2084
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2084
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: