Provider Demographics
NPI:1487625893
Name:CORREALE, SUZANNE MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:CORREALE
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 1:2800 S GORDON ST
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511
Mailing Address - Country:US
Mailing Address - Phone:281-331-8681
Mailing Address - Fax:281-585-4582
Practice Address - Street 1:2800 S GORDON ST
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511
Practice Address - Country:US
Practice Address - Phone:281-331-8681
Practice Address - Fax:281-585-4582
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4245TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146053701Medicaid
TX146053701Medicaid
TX00114SMedicare ID - Type Unspecified