Individual
XIOMARA IVELLISSE MATOS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
CARR. 2 KM 84.2, BO. CARRIZALES, HATILLO, PR 00659
(787) 820-5378
(787) 820-5409
Mailing address
6402 TANZANITE DR, KILLEEN, TX 76542-3325
(787) 644-0957
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
579
PR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100574
LA CRUZ AZUL
PR
01
—
56760MA
TRIPLE SSS
PR
01
—
P927
FIRST MEDICAL
PR
Enumeration date
07/10/2006
Last updated
06/26/2017
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