Provider Demographics
NPI:1023009149
Name:GONCALVES, TERESA (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GONCALVES
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 1:160 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4706
Mailing Address - Country:US
Mailing Address - Phone:407-775-4654
Mailing Address - Fax:407-834-6082
Practice Address - Street 1:2917 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4413
Practice Address - Country:US
Practice Address - Phone:407-423-2030
Practice Address - Fax:407-423-7354
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620538100Medicaid
FL20934VMedicare PIN
FL20934UMedicare PIN
FL20934WMedicare PIN
FL620538100Medicaid