Provider Demographics
NPI:1649337452
Name:CORSELLO, EDWARD (DC)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:CORSELLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4861
Mailing Address - Country:US
Mailing Address - Phone:203-381-1800
Mailing Address - Fax:203-381-1801
Practice Address - Street 1:3333 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4861
Practice Address - Country:US
Practice Address - Phone:203-381-1800
Practice Address - Fax:203-381-1801
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT1562111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001562CT04OtherANTHEM ID
V01958Medicare ID - Type Unspecified