Provider Demographics
NPI:1740238765
Name:CORRO, PRUDENCIO C (MD)
Entity Type:Individual
Prefix:
First Name:PRUDENCIO
Middle Name:C
Last Name:CORRO
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 1:673 RITTER DR
Mailing Address - Street 2:
Mailing Address - City:GLEN MORGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25813-7707
Mailing Address - Country:US
Mailing Address - Phone:304-252-0775
Mailing Address - Fax:304-255-6688
Practice Address - Street 1:673 RITTER DR
Practice Address - Street 2:
Practice Address - City:GLEN MORGAN
Practice Address - State:WV
Practice Address - Zip Code:25813-7707
Practice Address - Country:US
Practice Address - Phone:304-252-0775
Practice Address - Fax:304-255-6688
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5862207Y00000X
WV9578207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0101068000Medicaid
D49233Medicare UPIN
WV0101068000Medicaid