Provider Demographics
NPI:1942425319
Name:BURGOS-IRIZARRY, IVETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:IVETTE
Middle Name:
Last Name:BURGOS-IRIZARRY
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 1:2050 PONCE BY PASS
Mailing Address - Street 2:PLAZA DEL CARIBE SUITE 101
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:939-717-0257
Mailing Address - Fax:
Practice Address - Street 1:2050 PONCE BY PASS
Practice Address - Street 2:SUITE 101
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717
Practice Address - Country:US
Practice Address - Phone:787-259-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-8111938OtherTAX ID#