Provider Demographics
NPI:1184753055
Name:ROMAN-MORA, LIZA
Entity type:Individual
Prefix:DR
First Name:LIZA
Middle Name:
Last Name:ROMAN-MORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141176
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-1176
Mailing Address - Country:US
Mailing Address - Phone:787-510-8184
Mailing Address - Fax:
Practice Address - Street 1:ARECIBO SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00614-1176
Practice Address - Country:US
Practice Address - Phone:787-510-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRU95205Medicare UPIN