Provider Demographics
NPI:1083047336
Name:ULLOA, JOVANNY (OD)
Entity Type:Individual
Prefix:
First Name:JOVANNY
Middle Name:
Last Name:ULLOA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 CALLE CORALINA
Mailing Address - Street 2:ROSEVILLE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-9634
Mailing Address - Country:US
Mailing Address - Phone:787-210-6092
Mailing Address - Fax:
Practice Address - Street 1:SUITE A-12
Practice Address - Street 2:SANTA MARIA SHOPPING CTR
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:939-336-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist