Provider Demographics
NPI:1104587757
Name:GLAUCOMA SPECIALISTS OF PUERTO RICO LLC
Entity type:Organization
Organization Name:GLAUCOMA SPECIALISTS OF PUERTO RICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:J
Authorized Official - Last Name:VIVES ALVARADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-485-3480
Mailing Address - Street 1:URB LOS PASEOS
Mailing Address - Street 2:1 PASEO SERENO
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6469
Mailing Address - Country:US
Mailing Address - Phone:787-485-3480
Mailing Address - Fax:
Practice Address - Street 1:AVE. DE DIEGO 369
Practice Address - Street 2:TORRE SAN FRANCISCO SUITE 310
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00923
Practice Address - Country:US
Practice Address - Phone:787-767-8872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1902207459Medicaid
PR21279OtherSTATE LICENCE