MEDICARE: DR. AMANDA DANETTE GONZALES O.D.

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	7553TG	TX

General Provider Information

NPI Number	:	1356657985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA DANETTE GONZALES O.D.

Provider Business Mailing Address
First Line	:	PO BOX 1742
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76244-1742
Country	:	US
Telephone Number	:	682-418-1156
Fax Number	:	682-253-6738

Provider Business Practice Location Address
First Line	:	5336 GOLDEN TRIANGLE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4406
Country	:	US
Telephone Number	:	806-577-7839
Fax Number	:

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

Provider Enumeration Date	:	08/20/2010
Last Update Date	:	06/10/2024

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