Healthcare Provider Details

I. General information

NPI: 1346092996
Provider Name (Legal Business Name): IDELISH GONZALEZ OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IDELISH GONZALEZ OD

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 W NOLANA AVE
MCALLEN TX
78504-3091
US

IV. Provider business mailing address

907 REGAL DR
PHARR TX
78577-7714
US

V. Phone/Fax

Practice location:
  • Phone: 956-631-3366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11094TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: