Provider Demographics
NPI:1154973576
Name:MOREL TIRADO, KORAIMA
Entity type:Individual
Prefix:
First Name:KORAIMA
Middle Name:
Last Name:MOREL TIRADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 W 190 S
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3833
Mailing Address - Country:US
Mailing Address - Phone:252-292-0037
Mailing Address - Fax:
Practice Address - Street 1:1035 W 190 S
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3833
Practice Address - Country:US
Practice Address - Phone:252-292-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR87863208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT227885472OtherDRIVERS LIC.