Provider Demographics
NPI:1215249651
Name:MCKALLAGAT, CORISSA ANNE (OD)
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:ANNE
Last Name:MCKALLAGAT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4159
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03802-4159
Mailing Address - Country:US
Mailing Address - Phone:603-828-9601
Mailing Address - Fax:603-430-3076
Practice Address - Street 1:50 FOX RUN RD
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:NH
Practice Address - Zip Code:03801-2851
Practice Address - Country:US
Practice Address - Phone:603-828-9601
Practice Address - Fax:603-430-3076
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH0844152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist