Provider Demographics
NPI:1003196783
Name:GONZALEZ, HEIDI MARIE (OD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:MARIE
Other - Last Name:MAULDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:470 TURQUOISE BCH DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-3061
Mailing Address - Country:US
Mailing Address - Phone:334-791-0546
Mailing Address - Fax:
Practice Address - Street 1:4263 LEGENDARY DR
Practice Address - Street 2:STE J-105
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5392
Practice Address - Country:US
Practice Address - Phone:850-389-6132
Practice Address - Fax:850-583-3632
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist