MEDICARE: DR. IVETTE GONZALEZ 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	474	PR

General Provider Information

NPI Number	:	1750456109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVETTE GONZALEZ O.D.

Provider Business Mailing Address
First Line	:	131 AVE WINSTON CHURCHILL STE A
Second Line	:	EL SENORIAL
City	:	SAN JUAN
State	:	PR
Zip	:	00926-6012
Country	:	US
Telephone Number	:	787-764-6589
Fax Number	:	787-758-1981

Provider Business Practice Location Address
First Line	:	131 AVE WINSTON CHURCHILL STE A
Second Line	:	EL SENORIAL
City	:	SAN JUAN
State	:	PR
Zip	:	00926-6012
Country	:	US
Telephone Number	:	787-764-6589
Fax Number	:	787-758-1981

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	07/08/2007

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