Provider Demographics
NPI:1255316493
Name:REALI, BETH A (OD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:REALI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:REALI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4170 PENNEMITE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14487-9625
Mailing Address - Country:US
Mailing Address - Phone:585-346-3422
Mailing Address - Fax:
Practice Address - Street 1:3333 W HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3543
Practice Address - Country:US
Practice Address - Phone:585-424-5970
Practice Address - Fax:585-424-5973
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
122289OtherCOLE MANAGED CARE
NY5235OtherEYE MED
NY101990OtherHMO PREFERRED CARE
NY01436039Medicaid
NYP010005235OtherBLUE CHOICE HMO
NYP010005235OtherBLUE CHOICE HMO
NY11920BMedicare ID - Type Unspecified