Provider Demographics
NPI:1710147566
Name:CORONADO, MYRNA (MD)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:CORONADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-428-1330
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:865 3RD AVE
Practice Address - Street 2:SUITE 133
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1300
Practice Address - Country:US
Practice Address - Phone:619-428-1330
Practice Address - Fax:619-427-0134
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112627207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine