Provider Demographics
NPI:1326249889
Name:CORRALES, GUSTAVO A (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:CORRALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:410 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4412
Mailing Address - Country:US
Mailing Address - Phone:703-532-0728
Mailing Address - Fax:
Practice Address - Street 1:410 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046
Practice Address - Country:US
Practice Address - Phone:703-532-0728
Practice Address - Fax:888-972-9036
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT187242207W00000X
NY003086207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY650A21OtherEMPIRE BLUE CROSS BLUE SHIELD
NY650A21OtherEMPIRE BLUE CROSS BLUE SHIELD