Provider Demographics
NPI:1356408017
Name:GONZALES, ROBERT PETER (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PETER
Last Name:GONZALES
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 1:1415 N BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3303
Mailing Address - Country:US
Mailing Address - Phone:714-543-9022
Mailing Address - Fax:
Practice Address - Street 1:1415 N BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3303
Practice Address - Country:US
Practice Address - Phone:714-543-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7476T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074760Medicaid
CASD0074760Medicaid