Healthcare Provider Details

I. General information

NPI: 1659361426
Provider Name (Legal Business Name): CARLOS M. CEBOLLERO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YOKOTA AB
FUSSA JAPAN
96328
JP

IV. Provider business mailing address

PSC 78 BOX 2093 APO AP
FUSSA JAPAN
96326-0020
JP

V. Phone/Fax

Practice location:
  • Phone: 315-225-8404
  • Fax:
Mailing address:
  • Phone: 315-227-4853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number281
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: