Provider Demographics
NPI:1457097412
Name:CORDOVA, VANESSA MARIE (OD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:CORDOVA
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:PO BOX 2282
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-2282
Mailing Address - Country:US
Mailing Address - Phone:787-256-6060
Mailing Address - Fax:
Practice Address - Street 1:CARR 3 KM 19.9 EAST MEDICAL PROFESSIONAL CENTER
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-256-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR757OtherLICENSE OD