Provider Demographics
NPI:1568080828
Name:LONGA, MAIVYS HERNANDEZ (OD)
Entity type:Individual
Prefix:DR
First Name:MAIVYS
Middle Name:HERNANDEZ
Last Name:LONGA
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 NE 2ND PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-8837
Mailing Address - Country:US
Mailing Address - Phone:305-764-9865
Mailing Address - Fax:
Practice Address - Street 1:16960 ALICO MISSION WAY UNIT B204
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4844
Practice Address - Country:US
Practice Address - Phone:305-764-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2190DT152W00000X
FLOPC6227152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist