Provider Demographics
NPI:1679845739
Name:COELLO, MARY R (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:R
Last Name:COELLO
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:1015 TRAVELERS TRL NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2870
Mailing Address - Country:US
Mailing Address - Phone:770-815-1916
Mailing Address - Fax:
Practice Address - Street 1:4166 BUFORD HWY NE
Practice Address - Street 2:PLAZA FIESTA MALL SUITE S6-T5
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-1081
Practice Address - Country:US
Practice Address - Phone:404-855-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT-002681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist