Provider Demographics
NPI:1235166109
Name:GONZALEZ, MARILYN S (OD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:S
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:I
Other - Last Name:SAIKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 E. FLAMINGO RD.
Mailing Address - Street 2:STE 20
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121
Mailing Address - Country:US
Mailing Address - Phone:702-434-9919
Mailing Address - Fax:702-319-2158
Practice Address - Street 1:3300 E. FLAMINGO RD
Practice Address - Street 2:STE 20
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121
Practice Address - Country:US
Practice Address - Phone:702-434-9919
Practice Address - Fax:702-319-2158
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002502049Medicaid
NVU65600Medicare UPIN
NVV102972Medicare PIN