Provider Demographics
NPI:1316581911
Name:MALDONADO, GISELLE MARIE (LIC OPTICO)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:MARIE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:LIC OPTICO
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 113
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00715-0113
Mailing Address - Country:US
Mailing Address - Phone:787-612-9301
Mailing Address - Fax:
Practice Address - Street 1:BO CANAS CARR 10 KM 0.1
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728
Practice Address - Country:US
Practice Address - Phone:787-612-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1358156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician