Provider Demographics
NPI:1922302868
Name:OPTICA CDTGMSP
Entity Type:Organization
Organization Name:OPTICA CDTGMSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAYAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-780-9196
Mailing Address - Street 1:B-7 SANTA CRUZ
Mailing Address - Street 2:URB SANTA CRUZ
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:B-7 SANTA CRUZ
Practice Address - Street 2:URB SANTA CRUZ
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-780-9316
Practice Address - Fax:787-778-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038436400Medicaid