Provider Demographics
NPI:1588231211
Name:GONZALEZ PENA, JOSUE OLAF (OD)
Entity Type:Individual
Prefix:
First Name:JOSUE
Middle Name:OLAF
Last Name:GONZALEZ PENA
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 1:2190 COUNTRY DR S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9459
Mailing Address - Country:US
Mailing Address - Phone:503-990-3881
Mailing Address - Fax:
Practice Address - Street 1:101 NW 12TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-9145
Practice Address - Country:US
Practice Address - Phone:360-687-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61185440152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist