Healthcare Provider Details

I. General information

NPI: 1619592607
Provider Name (Legal Business Name): GISSELLE STEPHANIE CALERO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 SHERIDAN ST STE 102B
HOLLYWOOD FL
33021-1407
US

IV. Provider business mailing address

10676 NW 19TH ST
DORAL FL
33172-2542
US

V. Phone/Fax

Practice location:
  • Phone: 954-287-2010
  • Fax: 305-723-1910
Mailing address:
  • Phone: 786-465-4836
  • Fax: 305-723-1910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5804
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: