Provider Demographics
NPI:1003150129
Name:ALFONSO, MARIA THERESA GOZUN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIA THERESA
Middle Name:GOZUN
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11134 RANCHO CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4671
Mailing Address - Country:US
Mailing Address - Phone:858-673-1084
Mailing Address - Fax:
Practice Address - Street 1:539 PARKWAY PLZ
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2532
Practice Address - Country:US
Practice Address - Phone:619-441-0138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist