Provider Demographics
NPI:1245291194
Name:DE CORRAL, LUIS R (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:R
Last Name:DE CORRAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:R
Other - Last Name:DE CORRAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10431
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-0431
Mailing Address - Country:US
Mailing Address - Phone:787-781-2565
Mailing Address - Fax:787-782-9524
Practice Address - Street 1:AVE JESUS T PINERO 1250 CAPARRA TERRACE
Practice Address - Street 2:CENTRO OFTALMOLOGICO METROPOLITANO CSP
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-781-2565
Practice Address - Fax:787-782-9524
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE31119Medicare UPIN
PR0024161FMedicare PIN