Provider Demographics
NPI:1720720188
Name:PROFESSIONAL OPHTHALOMOLOGY GROUP LLC
Entity Type:Organization
Organization Name:PROFESSIONAL OPHTHALOMOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SILVINO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-250-0812
Mailing Address - Street 1:PO BOX 21368
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-1368
Mailing Address - Country:US
Mailing Address - Phone:787-250-0812
Mailing Address - Fax:787-753-2378
Practice Address - Street 1:708 AVE. PONCE D LEON
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00919-5013
Practice Address - Country:US
Practice Address - Phone:787-250-0812
Practice Address - Fax:787-753-2378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty