Provider Demographics
NPI:1679670301
Name:CORONA, MARIO L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:L
Last Name:CORONA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2905 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2063
Mailing Address - Country:US
Mailing Address - Phone:510-841-0411
Mailing Address - Fax:510-845-5030
Practice Address - Street 1:2905 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2063
Practice Address - Country:US
Practice Address - Phone:510-841-0411
Practice Address - Fax:510-845-5030
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA48346207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A483460Medicaid
CA00A483460Medicare ID - Type UnspecifiedPROVIDER NUMBER
CA00A483460Medicaid