Provider Demographics
NPI:1376510404
Name:CERDA, JUAN EVERARDO (OD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:EVERARDO
Last Name:CERDA
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 1:1313 S CAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-6227
Mailing Address - Country:US
Mailing Address - Phone:956-783-5500
Mailing Address - Fax:956-783-5660
Practice Address - Street 1:317 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-4801
Practice Address - Country:US
Practice Address - Phone:956-686-7435
Practice Address - Fax:956-686-6956
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05382TG152W00000X, 152W00000X
TX5382TG152WL0500X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041908701Medicaid
TX041908701Medicaid
8F3074Medicare PIN
TX83235EMedicare ID - Type UnspecifiedGROUP NUMBER