Provider Demographics
NPI:1083724322
Name:GONZALEZ, JAIME RENE (OD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:RENE
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2634 S CARRIER PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5005
Mailing Address - Country:US
Mailing Address - Phone:972-641-0011
Mailing Address - Fax:
Practice Address - Street 1:2634 S CARRIER PKWY
Practice Address - Street 2:101
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5070
Practice Address - Country:US
Practice Address - Phone:972-641-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6968T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist