Provider Demographics
NPI:1518973601
Name:CORREA, JOSE M (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:CORREA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:
Other - Last Name:CORREA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:112 MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:NORTHBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1914
Mailing Address - Country:US
Mailing Address - Phone:508-393-7807
Mailing Address - Fax:508-393-8608
Practice Address - Street 1:112 MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:NORTHBORO
Practice Address - State:MA
Practice Address - Zip Code:01532-1914
Practice Address - Country:US
Practice Address - Phone:508-393-7807
Practice Address - Fax:508-393-8608
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3070425Medicaid
MA3070425Medicaid