Provider Demographics
NPI:1487653366
Name:COLON, LIZA (OD)
Entity Type:Individual
Prefix:DR
First Name:LIZA
Middle Name:
Last Name:COLON
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 30
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-0030
Mailing Address - Country:US
Mailing Address - Phone:787-849-0303
Mailing Address - Fax:787-849-0302
Practice Address - Street 1:GALERIA 100 SHOPPING CENTER LOCAL 2
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-0062
Practice Address - Country:US
Practice Address - Phone:787-254-0303
Practice Address - Fax:787-255-0302
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38583400Medicaid
PROV683Medicaid