Provider Demographics
NPI:1154330967
Name:CORRELL, PAUL JEFFRY
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JEFFRY
Last Name:CORRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2288
Mailing Address - Country:US
Mailing Address - Phone:608-231-2502
Mailing Address - Fax:608-231-2949
Practice Address - Street 1:2725 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2288
Practice Address - Country:US
Practice Address - Phone:608-231-2502
Practice Address - Fax:608-231-2949
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
T61695Medicare UPIN
WI33559300Medicare ID - Type Unspecified