Provider Demographics
NPI:1639233067
Name:NORIEGA, GERARDO (OD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:NORIEGA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16111 SAN PEDRO AVE STE 123
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-3063
Mailing Address - Country:US
Mailing Address - Phone:210-545-5755
Mailing Address - Fax:210-545-5855
Practice Address - Street 1:16111 SAN PEDRO AVE STE 123
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3063
Practice Address - Country:US
Practice Address - Phone:210-545-5755
Practice Address - Fax:210-545-5855
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04854T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E22TMedicare ID - Type Unspecified
TXU52343Medicare UPIN