Provider Demographics
NPI:1427014166
Name:GONZALES, MARIO J (OD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:GONZALES
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 1:1369 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-5489
Mailing Address - Country:US
Mailing Address - Phone:510-592-1630
Mailing Address - Fax:510-724-0202
Practice Address - Street 1:1369 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-5489
Practice Address - Country:US
Practice Address - Phone:510-592-1630
Practice Address - Fax:510-724-0202
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM473152W00000X
CA10797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000L1409Medicare ID - Type Unspecified
U63827Medicare UPIN