Provider Demographics
NPI:1124064852
Name:CORSO, MAGDALENNE MARIE (MD)
Entity type:Individual
Prefix:
First Name:MAGDALENNE
Middle Name:MARIE
Last Name:CORSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAGDALENNE
Other - Middle Name:MARIE
Other - Last Name:BROWARSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19260 SW 65TH AVE
Mailing Address - Street 2:STE 275
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-5708
Mailing Address - Country:US
Mailing Address - Phone:503-691-2519
Mailing Address - Fax:503-659-8984
Practice Address - Street 1:19260 SW 65TH AVE
Practice Address - Street 2:STE 275
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5708
Practice Address - Country:US
Practice Address - Phone:503-691-2519
Practice Address - Fax:503-659-8984
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276009Medicaid