Provider Demographics
NPI:1720189855
Name:CONDE, MANUEL A (OD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:A
Last Name:CONDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 JOHN WILL HARRIS RD.
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-765-1915
Mailing Address - Fax:787-765-9854
Practice Address - Street 1:ELEANOR ROOSEVELT ST
Practice Address - Street 2:# 118
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00919
Practice Address - Country:US
Practice Address - Phone:787-765-1915
Practice Address - Fax:787-765-9854
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR273152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5-0079DMedicare ID - Type Unspecified