Provider Demographics
NPI:1487927331
Name:MANUEL D GONZALEZ, O.D., INC
Entity type:Organization
Organization Name:MANUEL D GONZALEZ, O.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:562-868-2418
Mailing Address - Street 1:11552 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3110
Mailing Address - Country:US
Mailing Address - Phone:562-868-2418
Mailing Address - Fax:562-868-7043
Practice Address - Street 1:11552 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3110
Practice Address - Country:US
Practice Address - Phone:562-868-2418
Practice Address - Fax:562-868-7043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7199 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0071990Medicaid
CA0443714Medicare UPIN
CAOP7199Medicare PIN