Provider Demographics
NPI:1902875024
Name:IVONNET, PEDRO IGNACIO (OD)
Entity type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:IGNACIO
Last Name:IVONNET
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11244 NW 46TH LN
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4346
Mailing Address - Country:US
Mailing Address - Phone:786-417-2717
Mailing Address - Fax:
Practice Address - Street 1:1405 NW 107TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2703
Practice Address - Country:US
Practice Address - Phone:305-594-6339
Practice Address - Fax:305-594-6249
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3240152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5578Medicare ID - Type Unspecified
FLU89686Medicare UPIN