Provider Demographics
NPI:1891743365
Name:CORREDERA, WILFREDO (MD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:CORREDERA
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 1:113 HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8123
Mailing Address - Country:US
Mailing Address - Phone:863-465-7010
Mailing Address - Fax:863-465-7266
Practice Address - Street 1:113 HEALTH WAY
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7920
Practice Address - Country:US
Practice Address - Phone:863-657-0104
Practice Address - Fax:863-465-4223
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18577OtherBLUE CROSS
FL372499900Medicaid
FL372499900Medicaid
FL18577XMedicare PIN
FL18577Medicare PIN
FL18577WMedicare PIN
FL18577YMedicare PIN
FL18577OtherBLUE CROSS