Provider Demographics
NPI:1558587048
Name:GONZALES, LORI MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:MICHELLE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8630 TARTAN WALK LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77075-4824
Mailing Address - Country:US
Mailing Address - Phone:713-991-3697
Mailing Address - Fax:
Practice Address - Street 1:1000 SAN JACINTO MALL
Practice Address - Street 2:(SEARS BLDG.)
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-8355
Practice Address - Country:US
Practice Address - Phone:281-421-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06584TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX06584TGOtherSTATE LICENSE NUMBER
TXA0140255OtherDPS REGISTRATION NUMBER