Provider Demographics
NPI:1225160518
Name:PERREAULT, ELISA BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:BETH
Last Name:PERREAULT
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 1:65 WOLF RD
Mailing Address - Street 2:STE 106
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-2621
Mailing Address - Country:US
Mailing Address - Phone:518-463-1707
Mailing Address - Fax:518-949-2499
Practice Address - Street 1:65 WOLF RD
Practice Address - Street 2:STE 106
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-2621
Practice Address - Country:US
Practice Address - Phone:518-463-1707
Practice Address - Fax:518-949-2499
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT-005329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist