Provider Demographics
NPI:1700907037
Name:CHERESTAL, YOLLETTE
Entity Type:Individual
Prefix:MS
First Name:YOLLETTE
Middle Name:
Last Name:CHERESTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LIBERTY HEIGHTS AVE
Mailing Address - Street 2:MONDAWMIN MALL
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-8019
Mailing Address - Country:US
Mailing Address - Phone:410-523-8803
Mailing Address - Fax:410-728-1583
Practice Address - Street 1:2301 LIBERTY HEIGHTS AVE
Practice Address - Street 2:MONDAWMIN MALL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-8019
Practice Address - Country:US
Practice Address - Phone:410-523-8803
Practice Address - Fax:410-728-1583
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30253875156FX1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric Technician