Provider Demographics
NPI:1780027672
Name:GONZALES, MERRY Y (LDO)
Entity Type:Individual
Prefix:MS
First Name:MERRY
Middle Name:Y
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101A BOYLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2818
Mailing Address - Country:US
Mailing Address - Phone:206-324-2005
Mailing Address - Fax:206-325-0209
Practice Address - Street 1:1101A BOYLSTON AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2818
Practice Address - Country:US
Practice Address - Phone:206-324-2005
Practice Address - Fax:206-325-0209
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA551156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician