Healthcare Provider Details

I. General information

NPI: 1104587757
Provider Name (Legal Business Name): GLAUCOMA SPECIALISTS OF PUERTO RICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 10/19/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. DE DIEGO 369 TORRE SAN FRANCISCO SUITE 310
RIO PIEDRAS PR
00923
US

IV. Provider business mailing address

URB LOS PASEOS 1 PASEO SERENO
SAN JUAN PR
00926-6469
US

V. Phone/Fax

Practice location:
  • Phone: 787-767-8872
  • Fax:
Mailing address:
  • Phone: 787-485-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLOS J VIVES ALVARADO
Title or Position: SOLE OWNER
Credential: MD
Phone: 787-485-3480