Healthcare Provider Details

I. General information

NPI: 1609830298
Provider Name (Legal Business Name): GASPARE JOSEPH CORRAO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMMANDING OFFICER ATTN: SENIOR MEDICAL DEPARTMENT REPRESENTATIVE
FPO AP
96674
US

IV. Provider business mailing address

91-1025 KAIHANUPA ST
EWA BEACH HI
96706-5062
US

V. Phone/Fax

Practice location:
  • Phone: 808-471-2098
  • Fax:
Mailing address:
  • Phone: 808-471-2098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: