Basic Information
| Provider Information | |||||||||
| NPI: | 1871750133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | ENRIQUE | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7037954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 6178 OXON HILL RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | OXON HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207453161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018395555 | ||||||||
| FaxNumber: | 3018391867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 12/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002572 | GA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 0618002532 | VA | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | DA 2084 | MD | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WS0006X | DA 2084 | MD | N | Eye and Vision Services Providers | Optometrist | Sports Vision | 152W00000X | TA2084 | MD | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.