Provider Demographics
NPI:1760504872
Name:BURGOS GONZALEZ, MAYDA I (OD)
Entity Type:Individual
Prefix:
First Name:MAYDA
Middle Name:I
Last Name:BURGOS GONZALEZ
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:ER 44
Mailing Address - Street 2:VIA ENRAMADA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-298-1356
Mailing Address - Fax:
Practice Address - Street 1:PLAZA LAS AMERICAS # 560
Practice Address - Street 2:TEODORO ROOSVELT
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-298-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist