Provider Demographics
NPI:1114185758
Name:CORLEY, MICHAEL JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEROME
Last Name:CORLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 OLIVE AVE # 564
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5142
Mailing Address - Country:US
Mailing Address - Phone:714-536-6715
Mailing Address - Fax:714-536-6795
Practice Address - Street 1:645 E MISSOURI AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1351
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104108207L00000X
AZ47786207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAY175YMedicare PIN
CAAY175Medicare PIN
CAAY175ZMedicare PIN