Provider Demographics
NPI:1669474151
Name:CORDERO, JUAN A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:A
Last Name:CORDERO
Suffix:JR
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 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5092
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:1100 GOETHALS DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3304
Practice Address - Country:US
Practice Address - Phone:509-942-3095
Practice Address - Fax:509-942-3097
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047531208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0237446OtherLABOR & INDUSTRIES
NY02597148Medicaid
WA8478687Medicaid
WA8869967Medicare PIN
NYRA3045Medicare ID - Type Unspecified
NY02597148Medicaid