Provider Demographics
NPI:1366584674
Name:CORIASSO, DAVID M (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:CORIASSO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:LUMM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1097 S STATE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1934
Mailing Address - Country:US
Mailing Address - Phone:810-653-4800
Mailing Address - Fax:810-412-4124
Practice Address - Street 1:1097 S STATE RD
Practice Address - Street 2:STE 1
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1934
Practice Address - Country:US
Practice Address - Phone:810-653-4800
Practice Address - Fax:810-412-4124
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU28846Medicare UPIN
MI410035931Medicare PIN
MI0M59680Medicare PIN