Basic Information
| Provider Information | |||||||||
| NPI: | 1316931793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVALLARO | ||||||||
| FirstName: | ANN-MARIE | ||||||||
| MiddleName: | M R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SERRANDER | ||||||||
| OtherFirstName: | ANN-MARIE | ||||||||
| OtherMiddleName: | M R | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1616 CLEAR LAKE CITY BLVD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770628069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812864343 | ||||||||
| FaxNumber: | 2812864344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 CLEAR LAKE CITY BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770628069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812864343 | ||||||||
| FaxNumber: | 2812864344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 04/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5062TG | TX | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.