Basic Information
| Provider Information | |||||||||
| NPI: | 1548306038 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROLANDO DELGADO VEGA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEAR VISION OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1135 | ||||||||
| Address2: | |||||||||
| City: | YAUCO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006981135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874257824 | ||||||||
| FaxNumber: | 7878565757 | ||||||||
| Practice Location | |||||||||
| Address1: | CAR128 KM 2.2 BO. SUSUA BAJA | ||||||||
| Address2: | YAUCO GALLERY SUITE 106 | ||||||||
| City: | YAUCO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874257824 | ||||||||
| FaxNumber: | 7878565757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | DELGADO | ||||||||
| AuthorizedOfficialFirstName: | ROLANDO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7874257824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 10171 | 01 | PR | AMERICAN HEALTH MEDICARE | OTHER | 6980094 | 01 | PR | HUMANA | OTHER | 2151042 | 01 | PR | PREFERRED HEALTH | OTHER | 50846 | 01 | PR | PMC | OTHER | 890753 | 01 | PR | MMM | OTHER | 101952 | 01 | PR | CRUZ AZUL DE PR | OTHER |