Provider Demographics
NPI:1114013943
Name:AMARAL, REBECCA D (OD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:AMARAL
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 1:1923 N SHAWANO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-7510
Mailing Address - Country:US
Mailing Address - Phone:920-982-8561
Mailing Address - Fax:920-982-9811
Practice Address - Street 1:1923 N SHAWANO ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-7510
Practice Address - Country:US
Practice Address - Phone:920-982-4561
Practice Address - Fax:920-982-9811
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38606100Medicaid
WIU75175Medicare UPIN
WI38606100Medicaid
WI000345385Medicare PIN