Provider Demographics
NPI:1093804080
Name:YEALY, NATALIA GORDILLO (OD)
Entity Type:Individual
Prefix:MRS
First Name:NATALIA
Middle Name:GORDILLO
Last Name:YEALY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NATALIA
Other - Middle Name:
Other - Last Name:GORDILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3687 WINGFIELD DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17406-6670
Mailing Address - Country:US
Mailing Address - Phone:786-512-5469
Mailing Address - Fax:
Practice Address - Street 1:360 SAINT CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4647
Practice Address - Country:US
Practice Address - Phone:717-757-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4281152W00000X
KY1826DT152W00000X
WAOD00004063152W00000X
CO2833152W00000X
PAOEG002732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12201642OtherCAQH