1760471338 NPI number — MARIATERESA CERAVOLO O.D.

Table of content: MARIATERESA CERAVOLO O.D. (NPI 1760471338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760471338 NPI number — MARIATERESA CERAVOLO O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERAVOLO
Provider First Name:
MARIATERESA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CERAVOLO
Provider Other First Name:
MARIATERESA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760471338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 WEST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANANDAIGUA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14424-1787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-394-2020
Provider Business Mailing Address Fax Number:
585-394-9261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 WEST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANANDAIGUA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14424-1723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-394-2020
Provider Business Practice Location Address Fax Number:
585-394-9261
Provider Enumeration Date:
10/17/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TUV006894 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02708047 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".