Provider Demographics
NPI:1376577916
Name:MATOS, XIOMARA IVELLISSE (OD)
Entity Type:Individual
Prefix:
First Name:XIOMARA
Middle Name:IVELLISSE
Last Name:MATOS
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 1:6402 TANZANITE DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-3325
Mailing Address - Country:US
Mailing Address - Phone:787-644-0957
Mailing Address - Fax:
Practice Address - Street 1:CARR. 2 KM 84.2
Practice Address - Street 2:BO. CARRIZALES
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-820-5378
Practice Address - Fax:787-820-5409
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR100574OtherLA CRUZ AZUL
PRP927OtherFIRST MEDICAL
PR56760MAOtherTRIPLE SSS
PRP927OtherFIRST MEDICAL