Provider Demographics
NPI:1952938383
Name:CORRAL, GUILHERME LOUBACK (DO)
Entity Type:Individual
Prefix:DR
First Name:GUILHERME
Middle Name:LOUBACK
Last Name:CORRAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 E 36TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2018
Mailing Address - Country:US
Mailing Address - Phone:512-743-2453
Mailing Address - Fax:
Practice Address - Street 1:136 E 36TH ST STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2018
Practice Address - Country:US
Practice Address - Phone:704-801-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2023-01795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program