Provider Demographics
NPI:1720342553
Name:GONZALES, COURTNEY MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:MARIE
Last Name:GONZALES
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 1:11450 N MERIDIAN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-4688
Mailing Address - Country:US
Mailing Address - Phone:317-872-8772
Mailing Address - Fax:
Practice Address - Street 1:11450 N MERIDIAN ST STE 120
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4688
Practice Address - Country:US
Practice Address - Phone:317-872-8772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004081A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN991378001Medicaid