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General NPI Number Information
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NPI Number | 1962698431
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Entity Type | Organization
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Legal Business Name | MICHELLE GONZALEZ OD PA
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 11/09/2007
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Provider Practice Location Address
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Address Line | 4300 W OAKLAND PARK BLVD
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City | LAUDERDALE LAKES
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State | FL
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Zip | 33313-1918
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Country | US
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Telephone | 954-484-0700
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Fax | 954-484-0705
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Provider Business Mailing Address
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Address Line | 4300 W OAKLAND PARK BLVD
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City | LAUDERDALE LAKES
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State | FL
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Zip | 33313-1918
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Country | US
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Telephone | 954-484-0700
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Fax | 954-484-0705
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHELLE GONZALEZ
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Credential | O.D.
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Telephone | 954-484-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC3797
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License Number State | FL
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