Provider Demographics
NPI:1598730301
Name:GONZALEZ, AGUSTIN L (OD)
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:L
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 1:3503 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2411
Mailing Address - Country:US
Mailing Address - Phone:972-235-3185
Mailing Address - Fax:
Practice Address - Street 1:811 N CENTRAL EXPY
Practice Address - Street 2:SUITE 1000
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-8815
Practice Address - Country:US
Practice Address - Phone:972-423-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4044152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7828209OtherAETNA
TX18FCOtherBCBS
9262207OtherPHCS
9262207OtherPHCS
7828209OtherAETNA