Provider Demographics
NPI:1346290384
Name:IBERN RODRIGUEZ, WANDA (OD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:IBERN RODRIGUEZ
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:COLINAS DE MONTE CARLO
Mailing Address - Street 2:E 32 CALLE 40
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-5818
Mailing Address - Country:US
Mailing Address - Phone:787-273-1227
Mailing Address - Fax:
Practice Address - Street 1:CENTRO VISULA DE CAGUAS
Practice Address - Street 2:B 11 VILLA CARMEN
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-273-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U95207Medicare UPIN
0055426Medicare ID - Type Unspecified