Provider Demographics
NPI:1295003614
Name:GONZALEZ, ROBERT MAURICIO (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MAURICIO
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 1:8312 LAKE MURRAY BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:SAN DIEGO CA
Mailing Address - State:CA
Mailing Address - Zip Code:92119
Mailing Address - Country:US
Mailing Address - Phone:619-464-2076
Mailing Address - Fax:619-464-8959
Practice Address - Street 1:8312 LAKE MURRAY BLVD
Practice Address - Street 2:STE C
Practice Address - City:SAN DIEGO CA
Practice Address - State:CA
Practice Address - Zip Code:92119
Practice Address - Country:US
Practice Address - Phone:619-464-2076
Practice Address - Fax:619-464-8959
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist