Provider Demographics
NPI:1700147576
Name:LEDET, DANIELLE GONZALEZ (OD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:GONZALEZ
Last Name:LEDET
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7104 S SHERIDAN RD STE 4
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2765
Mailing Address - Country:US
Mailing Address - Phone:918-496-2900
Mailing Address - Fax:
Practice Address - Street 1:1654 GADSDEN HWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3104
Practice Address - Country:US
Practice Address - Phone:205-655-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C85152W00000X
OK2941152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200830040AMedicaid