Healthcare Provider Details

I. General information

NPI: 1447774047
Provider Name (Legal Business Name): CORAL DUNDON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 NATURAL BRIDGE BLVD PATIENT CARE CENTER
ST LOUIS MO
63121
US

IV. Provider business mailing address

209C WILDROSE LN
MARION IL
62959-1223
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-5131
  • Fax: 314-516-5507
Mailing address:
  • Phone: 573-778-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2017020396
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: