Provider Demographics
NPI:1790974442
Name:DAVID J. CORALLO, D.O.
Entity Type:Organization
Organization Name:DAVID J. CORALLO, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAMBDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-938-3333
Mailing Address - Street 1:18586 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:OH
Mailing Address - Zip Code:44609-9799
Mailing Address - Country:US
Mailing Address - Phone:330-938-3333
Mailing Address - Fax:330-938-9375
Practice Address - Street 1:18586 5TH ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:OH
Practice Address - Zip Code:44609-9799
Practice Address - Country:US
Practice Address - Phone:330-938-3333
Practice Address - Fax:330-938-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006945C207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2241425Medicaid
OHDG3616OtherRAILROAD MEDICARE
OHSP01001Medicare PIN