Healthcare Provider Details

I. General information

NPI: 1326249889
Provider Name (Legal Business Name): GUSTAVO A CORRALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S WASHINGTON ST
FALLS CHURCH VA
22046
US

IV. Provider business mailing address

410 S WASHINGTON ST
FALLS CHURCH VA
22046-4412
US

V. Phone/Fax

Practice location:
  • Phone: 703-532-0728
  • Fax: 888-972-9036
Mailing address:
  • Phone: 703-532-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMT187242
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number003086
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: