Provider Demographics
NPI:1447387667
Name:SERALY, LORETTA G (OD)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:G
Last Name:SERALY
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 1:131 SPRINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:VENETIA
Mailing Address - State:PA
Mailing Address - Zip Code:15367-1324
Mailing Address - Country:US
Mailing Address - Phone:724-942-0503
Mailing Address - Fax:
Practice Address - Street 1:131 SPRINGDALE RD
Practice Address - Street 2:
Practice Address - City:VENETIA
Practice Address - State:PA
Practice Address - Zip Code:15367-1324
Practice Address - Country:US
Practice Address - Phone:724-942-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001740152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA712440ZQRGMedicare PIN