Provider Demographics
NPI:1205991791
Name:SOULEYRETTE, DALE (OD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:SOULEYRETTE
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 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:1709 N DIXIE AVE STE 101
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9496
Practice Address - Country:US
Practice Address - Phone:270-765-2020
Practice Address - Fax:502-765-4482
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1141DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011419Medicaid
KY77011419Medicaid
KYT82533Medicare UPIN