Healthcare Provider Details

I. General information

NPI: 1851475057
Provider Name (Legal Business Name): RICARDO RENE GONZALEZ O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E. EDINBURG AVE.
ELSA TX
78543-1137
US

IV. Provider business mailing address

PO BOX 1137
ELSA TX
78543-1137
US

V. Phone/Fax

Practice location:
  • Phone: 956-262-2020
  • Fax: 956-262-2080
Mailing address:
  • Phone: 956-262-2020
  • Fax: 956-262-2080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3344T
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3344TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: