Provider Demographics
NPI:1043569585
Name:MORREALE, MARK TIMOTHY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TIMOTHY
Last Name:MORREALE
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 1:2000 WALDEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225
Mailing Address - Country:US
Mailing Address - Phone:716-684-3960
Mailing Address - Fax:
Practice Address - Street 1:2000 WALDEN AVENUE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225
Practice Address - Country:US
Practice Address - Phone:716-684-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist