Provider Demographics
NPI:1801830153
Name:SO, CORALLI R (MD)
Entity Type:Individual
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First Name:CORALLI
Middle Name:R
Last Name:SO
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Gender:F
Credentials:MD
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Mailing Address - Street 1:244 W NEWTON ST
Mailing Address - Street 2:APARTMENT #3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6405
Mailing Address - Country:US
Mailing Address - Phone:781-979-3120
Mailing Address - Fax:781-979-3994
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3225
Practice Address - Country:US
Practice Address - Phone:781-979-3120
Practice Address - Fax:781-979-3994
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-07-05
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Provider Licenses
StateLicense IDTaxonomies
MA1522612085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0196321Medicaid
H45360Medicare UPIN
MA0196321Medicaid