Provider Demographics
NPI:1558477505
Name:DORTA, ISAMAR (OD)
Entity Type:Individual
Prefix:
First Name:ISAMAR
Middle Name:
Last Name:DORTA
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:HC 4 BOX 43001
Mailing Address - Street 2:
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-9434
Mailing Address - Country:US
Mailing Address - Phone:787-614-3373
Mailing Address - Fax:
Practice Address - Street 1:CARRIZALEZ WALLMART PLAZA DEL NORTE
Practice Address - Street 2:CARR # 2 KM.81.9 BO. CARRIZALEZ
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-817-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR625152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2533496OtherLICENSE