Provider Demographics
NPI:1013995547
Name:CORRELL, DONALD CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:CHARLES
Last Name:CORRELL
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:PO BOX 3788
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38303-3788
Mailing Address - Country:US
Mailing Address - Phone:731-425-6280
Mailing Address - Fax:731-425-4922
Practice Address - Street 1:708 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-425-6280
Practice Address - Fax:731-425-4922
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17640207P00000X
FLME118552207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3024304Medicaid
TN3024304Medicaid
TN3024305Medicare ID - Type Unspecified