Provider Demographics
NPI:1033517867
Name:GONZALEZ, BENEDICTE (OD MPH)
Entity Type:Individual
Prefix:DR
First Name:BENEDICTE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-1307
Mailing Address - Country:US
Mailing Address - Phone:323-234-9137
Mailing Address - Fax:
Practice Address - Street 1:3916 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-1307
Practice Address - Country:US
Practice Address - Phone:323-234-9137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15169152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist