Provider Demographics
NPI:1346092996
Name:GONZALEZ, IDELISH (OD)
Entity Type:Individual
Prefix:
First Name:IDELISH
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:IDELISH
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:907 REGAL DR
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-7714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:423 W NOLANA AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-3091
Practice Address - Country:US
Practice Address - Phone:956-631-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program