Provider Demographics
NPI:1699869941
Name:DAVILA RODRIGUEZ, LOURDES IVETTE (OD)
Entity type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:IVETTE
Last Name:DAVILA RODRIGUEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CALLE WILLIE ROSARIO
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-3252
Mailing Address - Country:US
Mailing Address - Phone:787-825-5458
Mailing Address - Fax:787-803-1993
Practice Address - Street 1:13 WILLIE ROSARIO
Practice Address - Street 2:SUITE 2
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769
Practice Address - Country:US
Practice Address - Phone:787-825-5458
Practice Address - Fax:787-803-1993
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
58026OtherSSS
2200033OtherHUMANA
38275OtherPROSSAM
PR660446068OtherMAPFRE
660446068OtherMCS OPTICA
890037OtherMMM
M000590OtherMENONITA
890037OtherMMM
58026Medicare ID - Type Unspecified
T81948Medicare UPIN