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General NPI Number Information
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NPI Number | 1811018948
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Entity Type | Organization
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Legal Business Name | CORVALAN UROLOGY MEDICAL CENTER
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 800 FAIRMOUNT AVE STE 420
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City | PASADENA
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State | CA
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Zip | 91105-3154
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Country | US
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Telephone | 818-500-0417
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Fax | 626-440-9178
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Provider Business Mailing Address
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Address Line | 800 FAIRMOUNT AVE STE 420
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City | PASADENA
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State | CA
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Zip | 91105-3154
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Country | US
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Telephone | 818-500-0417
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Fax | 626-440-9178
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAIME CORVALAN
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Credential | MD
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Telephone | 818-500-0417
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A25561
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License Number State | CA
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