MEDICARE: PONCE EYE MED INSTITUTE LCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1053901629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONCE EYE MED INSTITUTE LCC

Provider Business Mailing Address
First Line	:	44 CALLE MAYOR
Second Line	:	EDIFICIO ZAMORA
City	:	PONCE
State	:	PR
Zip	:	00730-3761
Country	:	US
Telephone Number	:	787-848-5353
Fax Number	:	787-259-4462

Provider Business Practice Location Address
First Line	:	44 CALLE MAYOR
Second Line	:	EDIFICIO ZAMORA
City	:	PONCE
State	:	PR
Zip	:	00730-3761
Country	:	US
Telephone Number	:	787-848-5353
Fax Number	:	787-259-4462

Authorized Official
Title or Position	:	OWNER
Name	:	MILTON E IRIZARRY
Credential	:	MD
Telephone Number	:	787-382-5195

Provider Enumeration Date	:	01/19/2021
Last Update Date	:	01/19/2021

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