Provider Demographics
NPI:1356657985
Name:GONZALES, AMANDA DANETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:DANETTE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DANETTE
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5336 GOLDEN TRIANGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4406
Mailing Address - Country:US
Mailing Address - Phone:806-577-7839
Mailing Address - Fax:
Practice Address - Street 1:5336 GOLDEN TRIANGLE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4406
Practice Address - Country:US
Practice Address - Phone:806-577-7839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7553TG152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist