Provider Demographics
NPI:1174551543
Name:GONZALEZ, KATHY RITTER (OD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:RITTER
Last Name:GONZALEZ
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:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7173
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:8051 VESTA AVE STE 2
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-2081
Practice Address - Country:US
Practice Address - Phone:330-468-0585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4383/T289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000208884OtherWORKER'S COMP
5740054OtherAETNA PPO/POS
0810886OtherAETNA HMO
P00203851OtherMEDICARE/PALMETTO
000000208884OtherANTHEM BC/BS
0161090001OtherMEDICARE SUPPLY PIN
R04383OtherSUMMA
GO0735676Medicare ID - Type Unspecified