Provider Demographics
NPI:1669793980
Name:CORACHEA, RONALDO SAN JUAN
Entity type:Individual
Prefix:
First Name:RONALDO
Middle Name:SAN JUAN
Last Name:CORACHEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7608 69TH PL APT 2B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7138
Mailing Address - Country:US
Mailing Address - Phone:347-886-6661
Mailing Address - Fax:
Practice Address - Street 1:7608 69TH PL APT 2B
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7138
Practice Address - Country:US
Practice Address - Phone:347-886-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018679-12251G0304X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics