Basic Information
| Provider Information | |||||||||
| NPI: | 1023009149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONCALVES | ||||||||
| FirstName: | TERESA | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077754654 | ||||||||
| FaxNumber: | 4078346082 | ||||||||
| Practice Location | |||||||||
| Address1: | 2917 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328044413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074232030 | ||||||||
| FaxNumber: | 4074237354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3423 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 620538100 | 05 | FL | MEDICAID |