Provider Demographics
NPI:1093206435
Name:GONZALEZ, VIRGEN (OPTICO)
Entity Type:Individual
Prefix:MS
First Name:VIRGEN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OPTICO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MALL OF SAN JUAN BLVD
Mailing Address - Street 2:SUITE #251 SAN JUAN 00924
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924
Mailing Address - Country:US
Mailing Address - Phone:939-777-2566
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:1000 MALL OF SAN JUAN BLVD
Practice Address - Street 2:SUITE #251 SAN JUAN 00924
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:939-777-2566
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00462156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty