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General NPI Number Information
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NPI Number | 1568080828
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Entity Type | Individual
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Provider Name | MAIVYS HERNANDEZ LONGA O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/13/2020
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Last Update Date | 04/18/2025
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Provider Practice Location Address
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Address Line | 16960 ALICO MISSION WAY UNIT B204
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City | FORT MYERS
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State | FL
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Zip | 33908-4844
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Country | US
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Telephone | 305-764-9865
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Fax |
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Provider Business Mailing Address
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Address Line | 2824 NE 2ND PL
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City | CAPE CORAL
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State | FL
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Zip | 33909-8837
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Country | US
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Telephone | 305-764-9865
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2190DT
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC6227
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License Number State | FL
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