MEDICARE: JUDDIE CORREOS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	9720TG	TX

General Provider Information

NPI Number	:	1275194755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDDIE CORREOS OD

Provider Business Mailing Address
First Line	:	12343 MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-6205
Country	:	US
Telephone Number	:	713-597-2020
Fax Number	:	281-990-6841

Provider Business Practice Location Address
First Line	:	12343 MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-6205
Country	:	US
Telephone Number	:	713-597-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2019
Last Update Date	:	11/12/2020

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Directions to “ JUDDIE CORREOS OD” Practice Location

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