Provider Demographics
NPI:1992885420
Name:DE JESUS, HERBERT (OD)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:
Last Name:DE JESUS
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:PO BOX 9386
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-9386
Mailing Address - Country:US
Mailing Address - Phone:787-653-2275
Mailing Address - Fax:
Practice Address - Street 1:2939 AVE EMILIO FAGOT STE 2
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-3656
Practice Address - Country:US
Practice Address - Phone:787-842-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR326152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR196386Medicare UPIN