Provider Demographics
NPI:1396966925
Name:CORRADINE, MARTHA MONICA (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:MONICA
Last Name:CORRADINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 PATRICK BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431
Mailing Address - Country:US
Mailing Address - Phone:937-431-1537
Mailing Address - Fax:
Practice Address - Street 1:ONE ELIZABETH PLACE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408
Practice Address - Country:US
Practice Address - Phone:937-229-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-2691-C261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2052380Medicaid
OHCO4083015Medicare ID - Type Unspecified
OH2052380Medicaid