Provider Demographics
NPI:1811980915
Name:ROSA REYES, VICTOR MANUEL (OD)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:MANUEL
Last Name:ROSA REYES
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:PO BOX 1229
Mailing Address - Street 2:
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777-1229
Mailing Address - Country:US
Mailing Address - Phone:787-752-1417
Mailing Address - Fax:787-787-9576
Practice Address - Street 1:HIGHWAY 185 K15.5
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-752-1417
Practice Address - Fax:787-787-9576
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR432152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U64121Medicare UPIN
PR88842Medicare ID - Type Unspecified