MEDICARE: JOHANNA GRISELL RAMOS BELEN OD

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	152W00000X	Optometrist	551	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2170311	OTHER	PR	DRIVER LISCENSE

General Provider Information

NPI Number	:	1083760821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANNA GRISELL RAMOS BELEN OD

Provider Business Mailing Address
First Line	:	CORAL 53
Second Line	:	REPTO PUEBLO NUEVO
City	:	SAN GERMAN
State	:	PR
Zip	:	00683
Country	:	US
Telephone Number	:	787-410-5774
Fax Number	:	787-833-9200

Provider Business Practice Location Address
First Line	:	53 CALLE CORAL
Second Line	:	REPTO PUEBLO NUEVO
City	:	SAN GERMAN
State	:	PR
Zip	:	00683-4306
Country	:	US
Telephone Number	:	787-410-5774
Fax Number	:	787-833-9200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	02/20/2012

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