Provider Demographics
NPI:1356333900
Name:GONZALEZ, LEONCIO V (OD)
Entity Type:Individual
Prefix:DR
First Name:LEONCIO
Middle Name:V
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 1:11760 BIRD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3549
Mailing Address - Country:US
Mailing Address - Phone:305-220-8333
Mailing Address - Fax:305-220-1971
Practice Address - Street 1:11760 BIRD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3549
Practice Address - Country:US
Practice Address - Phone:305-220-8333
Practice Address - Fax:305-220-1971
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-08-04
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLOP2772152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620109100Medicaid
FL1138160001Medicare NSC
FL620109100Medicaid