Provider Demographics
NPI:1568080828
Name:LONGA, MAIVYS HERNANDEZ (OD)
Entity Type:Individual
Prefix:DR
First Name:MAIVYS
Middle Name:HERNANDEZ
Last Name:LONGA
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 1:4101 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9310
Mailing Address - Country:US
Mailing Address - Phone:239-939-3456
Mailing Address - Fax:
Practice Address - Street 1:17966 N TAMIAMI TRL # 160
Practice Address - Street 2:
Practice Address - City:N FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-1414
Practice Address - Country:US
Practice Address - Phone:239-939-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2190DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist