Provider Demographics
NPI:1629065776
Name:CORREA, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CORREA
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:PO BOX 780007
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78278-0007
Mailing Address - Country:US
Mailing Address - Phone:210-977-8100
Mailing Address - Fax:210-921-1163
Practice Address - Street 1:8726 POTEET JOURDANTON FWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-2412
Practice Address - Country:US
Practice Address - Phone:210-977-8100
Practice Address - Fax:210-921-1163
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091613207R00000X
TXM3503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
205617688OtherCOMMERICAL INSURANCE
TX8W8890OtherBCBS TEXAS
TX8F4864Medicare PIN
205617688OtherCOMMERICAL INSURANCE