Healthcare Provider Details

I. General information

NPI: 1780027672
Provider Name (Legal Business Name): MERRY Y GONZALES LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101A BOYLSTON AVE
SEATTLE WA
98101-2818
US

IV. Provider business mailing address

1101A BOYLSTON AVE
SEATTLE WA
98101-2818
US

V. Phone/Fax

Practice location:
  • Phone: 206-324-2005
  • Fax: 206-325-0209
Mailing address:
  • Phone: 206-324-2005
  • Fax: 206-325-0209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number551
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: