MEDICARE: OMAR GONZALEZ OD

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	152W00000X	Optometrist	7234T	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275796179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMAR GONZALEZ OD

Provider Business Mailing Address
First Line	:	3814 W ILLINOIS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-8500
Country	:	US
Telephone Number	:	214-331-4700
Fax Number	:	214-331-4712

Provider Business Practice Location Address
First Line	:	3814 W ILLINOIS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-8500
Country	:	US
Telephone Number	:	214-331-4700
Fax Number	:	214-331-4712

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

Provider Enumeration Date	:	07/10/2008
Last Update Date	:	09/06/2022

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Directions to “ OMAR GONZALEZ OD” Practice Location

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