Provider Demographics
NPI:1376301515
Name:PERDOMO, VIRGINIA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:PERDOMO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13973 SW 46TH TER APT C223
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4433
Mailing Address - Country:US
Mailing Address - Phone:786-357-6748
Mailing Address - Fax:
Practice Address - Street 1:3773 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1601
Practice Address - Country:US
Practice Address - Phone:786-357-6748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOD7242156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician