Healthcare Provider Details

I. General information

NPI: 1255316493
Provider Name (Legal Business Name): BETH A REALI OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETH A REALI OD

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W HENRIETTA RD
ROCHESTER NY
14623-3543
US

IV. Provider business mailing address

4170 PENNEMITE RD
LIVONIA NY
14487-9625
US

V. Phone/Fax

Practice location:
  • Phone: 585-424-5970
  • Fax: 585-424-5973
Mailing address:
  • Phone: 585-346-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT005235
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: