Provider Demographics
NPI:1164874541
Name:GONZALEZ, NICOLAS ISMAEL III (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:ISMAEL
Last Name:GONZALEZ
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S ALBERTSON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-2905
Mailing Address - Country:US
Mailing Address - Phone:626-502-6438
Mailing Address - Fax:
Practice Address - Street 1:505 S ALBERTSON AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2905
Practice Address - Country:US
Practice Address - Phone:626-502-6438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33485152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist