Provider Demographics
NPI:1952839185
Name:MALAVE PEREZ, JORGE LUIS (OD)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:MALAVE PEREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198A AVE MONTEMAR
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-5563
Mailing Address - Country:US
Mailing Address - Phone:787-951-9258
Mailing Address - Fax:
Practice Address - Street 1:154 AVE PEDRO ALBIZU CAMPOS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5726
Practice Address - Country:US
Practice Address - Phone:787-951-9258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR729-416152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist