Provider Demographics
NPI:1629465604
Name:ADVANCED GLAUCOMA AND OPHTHALMOLOGY SERVICES
Entity Type:Organization
Organization Name:ADVANCED GLAUCOMA AND OPHTHALMOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-717-3068
Mailing Address - Street 1:RR 36 BOX 8233
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-9562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:572 AVE CESAR GONZALEZ
Practice Address - Street 2:HATO REY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-764-4066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17637207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty