Provider Demographics
NPI:1497800692
Name:GONZALEZ, MANUEL D (OD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:D
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 1:11552 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3110
Mailing Address - Country:US
Mailing Address - Phone:562-868-2418
Mailing Address - Fax:562-868-7043
Practice Address - Street 1:11552 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3110
Practice Address - Country:US
Practice Address - Phone:562-868-2418
Practice Address - Fax:562-868-7043
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7199 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0071990Medicaid
CA0443714Medicare UPIN
CAOP7199Medicare ID - Type Unspecified