Provider Demographics
NPI:1629371695
Name:LEONCIO V GONZALEZ OD PA
Entity Type:Organization
Organization Name:LEONCIO V GONZALEZ OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONCIO
Authorized Official - Middle Name:V
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-220-8333
Mailing Address - Street 1:11760 BIRD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3582
Mailing Address - Country:US
Mailing Address - Phone:305-220-8333
Mailing Address - Fax:305-220-1971
Practice Address - Street 1:11760 BIRD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3582
Practice Address - Country:US
Practice Address - Phone:305-220-8333
Practice Address - Fax:305-220-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP 2772332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1138160001OtherDME
FL620109100Medicaid
FL1138160001OtherDME