Provider Demographics
NPI:1295737591
Name:PADILLA, FERNANDO LUIS (OD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:LUIS
Last Name:PADILLA
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 1:134 CALLE CARACOL
Mailing Address - Street 2:ALTURAS DEL MAR
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-3186
Mailing Address - Country:US
Mailing Address - Phone:939-645-2686
Mailing Address - Fax:
Practice Address - Street 1:URB ALTURAS DEL MAR
Practice Address - Street 2:134 CARACOL
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-3186
Practice Address - Country:US
Practice Address - Phone:939-645-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR58055Medicare ID - Type UnspecifiedTRIPLE SSS