Healthcare Provider Details

I. General information

NPI: 1154705259
Provider Name (Legal Business Name): ISMAEL CORRAL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON STREET BOX 17
TORRANCE CA
90509
US

IV. Provider business mailing address

1000 W CARSON STREET BOX 17
TORRANCE CA
90509
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-2343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA145176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: