MEDICARE: MR. PABLO GONZALES III OPTICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician		TX
2	156FC0800X	Contact Lens Technician/Technologist

General Provider Information

NPI Number	:	1174120083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PABLO GONZALES III OPTICIAN

Provider Business Mailing Address
First Line	:	10114 STELLA LINK RD STE A-2
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-5300
Country	:	US
Telephone Number	:	713-808-9053
Fax Number	:	713-893-6916

Provider Business Practice Location Address
First Line	:	10114 STELLA LINK RD STE A-2
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-5300
Country	:	US
Telephone Number	:	713-808-9053
Fax Number	:	713-893-6916

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2020
Last Update Date	:	07/14/2023

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