Provider Demographics
NPI:1689187676
Name:MOHEEPUTH, GLENDA ALEMAN (OD)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:ALEMAN
Last Name:MOHEEPUTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:LOURDES
Other - Last Name:ALEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDO
Mailing Address - Street 1:19244 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-4500
Mailing Address - Country:US
Mailing Address - Phone:954-854-7910
Mailing Address - Fax:
Practice Address - Street 1:19244 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-4500
Practice Address - Country:US
Practice Address - Phone:954-854-7910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008707152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist