Provider Demographics
NPI:1013967512
Name:CORRALES-DIAZ, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:CORRALES-DIAZ
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 1:19245 7TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6551
Mailing Address - Country:US
Mailing Address - Phone:360-782-3500
Mailing Address - Fax:360-782-3540
Practice Address - Street 1:19245 7TH AVE NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6551
Practice Address - Country:US
Practice Address - Phone:360-782-3500
Practice Address - Fax:360-782-3540
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021573208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7915OtherREGENCE BLUE SHIELD
4586742OtherAETNA
WA1000428Medicaid
WA8919257OtherCRIME VICTIMS COMP
370002262OtherRAILROAD MEDICARE
WA75427OtherLABOR & INDUSTRIES
CO7915OtherREGENCE BLUE SHIELD
F47911Medicare UPIN
WAG000250702Medicare PIN
WAGAB02010Medicare PIN
AC2143282OtherDEA
WA8627705Medicaid
WAG000250633Medicare PIN
4586742OtherAETNA
CO7915OtherREGENCE BLUE SHIELD