Provider Demographics
NPI:1073692018
Name:ODINEAL, CORINNE ROUAULT (OD)
Entity Type:Individual
Prefix:DR
First Name:CORINNE
Middle Name:ROUAULT
Last Name:ODINEAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3262 FORTUNE CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-7847
Mailing Address - Country:US
Mailing Address - Phone:530-830-7007
Mailing Address - Fax:
Practice Address - Street 1:3133 PROFESSIONAL DR STE 14
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2463
Practice Address - Country:US
Practice Address - Phone:530-888-0670
Practice Address - Fax:530-888-8652
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8316 TPA152WP0200X, 152WV0400X, 152WX0102X, 156FC0801X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMO 1495680OtherDEA #
CAMO 1495680OtherDEA #