MEDICARE: DR. AUGUSTO C. CORELLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	0101239903	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	019567106	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1730171455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUGUSTO C. CORELLA M.D.

Provider Business Mailing Address
First Line	:	4660 KENMORE AVE
Second Line	:	SUITE 710
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1313
Country	:	US
Telephone Number	:	703-370-9002
Fax Number	:	703-370-2849

Provider Business Practice Location Address
First Line	:	4660 KENMORE AVE
Second Line	:	SUITE 710
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1313
Country	:	US
Telephone Number	:	703-370-9002
Fax Number	:	703-370-2849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	02/12/2021

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