Provider Demographics
NPI:1306997309
Name:CORREA, GERARDO (OD)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:CORREA
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:E ST. G14 TORREMOLINOS
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-850-5222
Mailing Address - Fax:
Practice Address - Street 1:CARR 3 350
Practice Address - Street 2:PLAZA PALMA REAL
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-4736
Practice Address - Country:US
Practice Address - Phone:787-850-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038264500Medicaid