MEDICARE: GREG CORONADO 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	4789TG	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00417953	OTHER	TX	MEDICARE RAILROAD PTAN

General Provider Information

NPI Number	:	1750491593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREG CORONADO OD

Provider Business Mailing Address
First Line	:	1110 NORTH GREENVILLE AVENUE
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002
Country	:	US
Telephone Number	:	972-396-0006
Fax Number	:	972-396-0004

Provider Business Practice Location Address
First Line	:	1110 NORTH GREENVILLE AVENUE
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002
Country	:	US
Telephone Number	:	972-396-0006
Fax Number	:	972-396-0004

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	09/19/2008

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Directions to “ GREG CORONADO OD” Practice Location

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