Provider Demographics
NPI:1588602619
Name:CORRALES, CONSUELO (MD)
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:
Last Name:CORRALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 E CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1708
Mailing Address - Country:US
Mailing Address - Phone:702-633-5410
Mailing Address - Fax:702-320-1639
Practice Address - Street 1:1219 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1708
Practice Address - Country:US
Practice Address - Phone:702-633-5410
Practice Address - Fax:702-320-1639
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4217208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE79727Medicare UPIN
NV32164Medicare ID - Type Unspecified