Healthcare Provider Details

I. General information

NPI: 1033970744
Provider Name (Legal Business Name): CENTRO OFTALMOLOGICO METROPOLITANO CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 AVE JESUS T PINERO
SAN JUAN PR
00921-1722
US

IV. Provider business mailing address

1114 AVE JESUS T PINERO
SAN JUAN PR
00921-1722
US

V. Phone/Fax

Practice location:
  • Phone: 787-781-3020
  • Fax: 787-781-3375
Mailing address:
  • Phone: 787-781-3020
  • Fax: 787-781-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: NESTOR A MEDINA
Title or Position: ADMINISTRADOR
Credential:
Phone: 787-781-3020