Provider Demographics
NPI:1942807128
Name:BURGOS, JOSE L (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:BURGOS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3GN2 VIA 65
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-4622
Mailing Address - Country:US
Mailing Address - Phone:787-299-5828
Mailing Address - Fax:
Practice Address - Street 1:1116 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-3802
Practice Address - Country:US
Practice Address - Phone:787-299-5828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR517156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician