Provider Demographics
NPI:1225126212
Name:CORALLO, DAVID J (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:CORALLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18586 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:OH
Mailing Address - Zip Code:44609-9799
Mailing Address - Country:US
Mailing Address - Phone:330-938-3333
Mailing Address - Fax:
Practice Address - Street 1:18586 5TH ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:OH
Practice Address - Zip Code:44609-9799
Practice Address - Country:US
Practice Address - Phone:330-938-3333
Practice Address - Fax:330-938-9375
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006945C207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH070016762OtherRAIL ROAD MEDICARE
OH2241425Medicaid
OH2241425Medicaid
OHH36984Medicare UPIN
OH4050711Medicare PIN