Healthcare Provider Details

I. General information

NPI: 1164835195
Provider Name (Legal Business Name): LUIS CARLOS CORRAL GUERRERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 FIFTH AVE
MCKEESPORT PA
15132-2422
US

IV. Provider business mailing address

1500 FIFTH AVENUE
MCKEESPORT PA
15132
US

V. Phone/Fax

Practice location:
  • Phone: 713-482-1059
  • Fax:
Mailing address:
  • Phone: 713-482-1059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT206946
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR2839
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: