Provider Demographics
NPI:1760471338
Name:CERAVOLO, MARIATERESA (OD)
Entity Type:Individual
Prefix:
First Name:MARIATERESA
Middle Name:
Last Name:CERAVOLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARIATERESA
Other - Middle Name:
Other - Last Name:CERAVOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:325 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1787
Mailing Address - Country:US
Mailing Address - Phone:585-394-2020
Mailing Address - Fax:585-394-9261
Practice Address - Street 1:325 WEST ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1723
Practice Address - Country:US
Practice Address - Phone:585-394-2020
Practice Address - Fax:585-394-9261
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006894152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02708047Medicaid
NY02708047Medicaid
NYV06210Medicare UPIN