Provider Demographics
NPI:1174729420
Name:GONZALEZ, MICHELLE (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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:P.O. BOX 39209
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339
Mailing Address - Country:US
Mailing Address - Phone:954-851-9966
Mailing Address - Fax:954-318-7360
Practice Address - Street 1:1 S.W. 129TH AVE
Practice Address - Street 2:STE 209
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027
Practice Address - Country:US
Practice Address - Phone:954-437-9300
Practice Address - Fax:954-437-9377
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist