Provider Demographics
NPI:1639224165
Name:CORRALES, MARK G (DPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:CORRALES
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-3615
Mailing Address - Country:US
Mailing Address - Phone:580-355-4540
Mailing Address - Fax:580-248-2012
Practice Address - Street 1:1810 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3615
Practice Address - Country:US
Practice Address - Phone:580-355-4540
Practice Address - Fax:580-248-2012
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK11511OtherPHARMACIST LICENSE NUMBER