Provider Demographics
NPI:1619977790
Name:CORALLO, DIANE M (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:CORALLO
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:485 ROYER DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-5102
Mailing Address - Country:US
Mailing Address - Phone:717-397-8259
Mailing Address - Fax:717-397-1786
Practice Address - Street 1:485 ROYER DR STE 103
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-5102
Practice Address - Country:US
Practice Address - Phone:717-560-4020
Practice Address - Fax:717-560-2919
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD042035E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000646989Medicaid
PA0012571430001Medicaid
PA37812OtherBLUE SHIELD
PA0012571430001Medicaid
PA671099EEAMedicare PIN
E83774Medicare UPIN