Basic Information
| Provider Information | |||||||||
| NPI: | 1174551543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | RITTER | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207170 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 8051 VESTA AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440672081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304680585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4383/T289 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000208884 | 01 | WORKER'S COMP | OTHER | 5740054 | 01 | AETNA PPO/POS | OTHER | 0810886 | 01 | AETNA HMO | OTHER | P00203851 | 01 | MEDICARE/PALMETTO | OTHER | 000000208884 | 01 | ANTHEM BC/BS | OTHER | 0161090001 | 01 | MEDICARE SUPPLY PIN | OTHER | R04383 | 01 | SUMMA | OTHER |