1265411540 NPI number — RICHARD COREA O.D.

Table of content: RICHARD COREA O.D. (NPI 1265411540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265411540 NPI number — RICHARD COREA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COREA
Provider First Name:
RICHARD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265411540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64481
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-933-7475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 BOULTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEL AIR
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21014-4255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-836-7010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TA1006 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 236623ZALT , issued by the state of ( MD ) . This identifiers is of the category "MEDICARE PIN".
  • Identifier: 091568800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: T69237 . This identifiers is of the category "MEDICARE UPIN".
  • Identifier: S719Z103 . This identifiers is of the category "MEDICARE ID-TYPE UNSPECIFIED".