Provider Demographics
NPI:1750491593
Name:CORONADO, GREG (OD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:CORONADO
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 1:1110 NORTH GREENVILLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002
Mailing Address - Country:US
Mailing Address - Phone:972-396-0006
Mailing Address - Fax:972-396-0004
Practice Address - Street 1:1110 NORTH GREENVILLE AVENUE
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002
Practice Address - Country:US
Practice Address - Phone:972-396-0006
Practice Address - Fax:972-396-0004
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4789TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00417953OtherMEDICARE RAILROAD PTAN
TX00E13V8Medicare ID - Type Unspecified
TXU45310Medicare UPIN