Provider Demographics
NPI:1407857774
Name:COROSO, JOSEPH G (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:G
Last Name:COROSO
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 1:104 METOXET ST
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-1932
Mailing Address - Country:US
Mailing Address - Phone:814-788-5555
Mailing Address - Fax:814-788-5655
Practice Address - Street 1:104 METOXET ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-1932
Practice Address - Country:US
Practice Address - Phone:814-788-5555
Practice Address - Fax:814-788-5655
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020779E207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC26230Medicare UPIN
PA007177Medicare ID - Type Unspecified