Provider Demographics
NPI:1952312324
Name:CONSULTORIO OPTOMETRICO DE SG, CSP
Entity Type:Organization
Organization Name:CONSULTORIO OPTOMETRICO DE SG, CSP
Other - Org Name:DR. LUIS E. MORA ANTONGIORGI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-892-1218
Mailing Address - Street 1:PO BOX 495
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-0495
Mailing Address - Country:US
Mailing Address - Phone:787-892-1218
Mailing Address - Fax:787-892-7480
Practice Address - Street 1:AVE. ANGEL C PEREZ #2
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-1218
Practice Address - Fax:787-892-7480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR403-0029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR50002OtherSSS
PR5211OtherIMC
PR6830042OtherHUMANA
PR890343OtherMMM
PR077-137OtherCRUZ AZUL
PR215264OtherPREFFERRED HEALTH
PR215264OtherPREFFERRED HEALTH
PR=========OtherPMC