Provider Demographics
NPI:1649036401
Name:CORDOVA, JOSE RAUL (OD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:RAUL
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:RAUL CORDOVA
Other - Last Name:CUEVAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16075 NW 64TH AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-7529
Mailing Address - Country:US
Mailing Address - Phone:786-285-7557
Mailing Address - Fax:
Practice Address - Street 1:1979 MARCUS AVE STE 206
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1002
Practice Address - Country:US
Practice Address - Phone:516-243-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty