Healthcare Provider Details

I. General information

NPI: 1245212539
Provider Name (Legal Business Name): CARLOS HUMBERTO CORRAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 W 2ND PL STE 280
LAKEWOOD CO
80228-1717
US

IV. Provider business mailing address

11700 W 2ND PL STE 280
LAKEWOOD CO
80228-1717
US

V. Phone/Fax

Practice location:
  • Phone: 720-321-8680
  • Fax: 720-321-8681
Mailing address:
  • Phone: 720-321-8680
  • Fax: 720-321-8681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG2120
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number90170
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number59284
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number101130
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: