Provider Demographics
NPI:1407439045
Name:CORELLA, CARLOS MARIO (RMA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MARIO
Last Name:CORELLA
Suffix:
Gender:M
Credentials:RMA
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:MARIO
Other - Last Name:CORELLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RMA
Mailing Address - Street 1:914 DEFOREST AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-2140
Mailing Address - Country:US
Mailing Address - Phone:319-621-3095
Mailing Address - Fax:844-883-6979
Practice Address - Street 1:914 DEFOREST AVE
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-2140
Practice Address - Country:US
Practice Address - Phone:319-621-3095
Practice Address - Fax:844-883-6979
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA190586246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty