Healthcare Provider Details

I. General information

NPI: 1396859682
Provider Name (Legal Business Name): MITHRA GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 659
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-273-3937
  • Fax:
Mailing address:
  • Phone: 585-273-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number48791
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number266016
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number266016
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: