Provider Demographics
NPI:1811790637
Name:VANDERSALL, COREY ISIDRO
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:ISIDRO
Last Name:VANDERSALL
Suffix:
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 1:2414 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1583
Mailing Address - Country:US
Mailing Address - Phone:234-284-5172
Mailing Address - Fax:
Practice Address - Street 1:2414 SHADOW LN
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1583
Practice Address - Country:US
Practice Address - Phone:234-284-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)