Provider Demographics
NPI:1215090113
Name:CALISTERIO, CORDELL A (OD)
Entity type:Individual
Prefix:
First Name:CORDELL
Middle Name:A
Last Name:CALISTERIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41418 CORRIANDER CT
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-4037
Mailing Address - Country:US
Mailing Address - Phone:586-726-8593
Mailing Address - Fax:586-726-8577
Practice Address - Street 1:18000 VERNIER RD
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-1046
Practice Address - Country:US
Practice Address - Phone:313-245-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU33213Medicare UPIN