Provider Demographics
NPI:1275796179
Name:GONZALEZ, OMAR (OD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:GONZALEZ
Suffix:
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 1:3814 W ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-8500
Mailing Address - Country:US
Mailing Address - Phone:214-331-4700
Mailing Address - Fax:214-331-4712
Practice Address - Street 1:3814 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-8500
Practice Address - Country:US
Practice Address - Phone:214-331-4700
Practice Address - Fax:214-331-4712
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7234T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210710401Medicaid
TX210710401Medicaid