Provider Demographics
NPI:1831399450
Name:ALTONAGA, GUILLERMO (OD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:ALTONAGA
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 1:1905 BAYHILL DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6303
Mailing Address - Country:US
Mailing Address - Phone:321-259-4990
Mailing Address - Fax:
Practice Address - Street 1:1905 BAYHILL DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-6303
Practice Address - Country:US
Practice Address - Phone:321-259-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-22
Last Update Date:2007-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOC 2437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU19096Medicare UPIN
FL20226AMedicare Oscar/Certification