Provider Demographics
NPI:1154705259
Name:CORRAL, ISMAEL JR
Entity type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:CORRAL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON STREET
Mailing Address - Street 2:BOX 17
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON STREET
Practice Address - Street 2:BOX 17
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90509
Practice Address - Country:US
Practice Address - Phone:310-222-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1451762080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program