Healthcare Provider Details

I. General information

NPI: 1447779202
Provider Name (Legal Business Name): LUIS ANTONIO GONZALEZ CORRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 E MONUMENT ST FL 4
BALTIMORE MD
21287-0020
US

IV. Provider business mailing address

1830 E MONUMENT ST FL 4
BALTIMORE MD
21287-0020
US

V. Phone/Fax

Practice location:
  • Phone: 443-287-4748
  • Fax: 410-614-8488
Mailing address:
  • Phone: 443-287-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD0096097
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberP06499
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: