Provider Demographics
NPI:1255521613
Name:VILLAGOMEZ, KAREN ANN (OD)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:ANN
Last Name:VILLAGOMEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:ANN
Other - Last Name:PUCHALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5941 WEDGEWOOD VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7368
Mailing Address - Country:US
Mailing Address - Phone:954-439-1373
Mailing Address - Fax:
Practice Address - Street 1:2905 N MILITARY TRL STE G
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2921
Practice Address - Country:US
Practice Address - Phone:561-684-5548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621278600Medicaid
FL621278600Medicaid