Provider Demographics
NPI:1568453058
Name:GONZALEZ, ALVARO (MD)
Entity Type:Individual
Prefix:DR
First Name:ALVARO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALVARO
Other - Middle Name:D
Other - Last Name:GONZALEZ-FERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2512
Mailing Address - Country:US
Mailing Address - Phone:918-458-3536
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3536
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35032895207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H87692Medicare UPIN
8HBJ89Medicare ID - Type Unspecified