Provider Demographics
NPI:1962539361
Name:CORVALAN, JOSE ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ALBERTO
Last Name:CORVALAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W 110TH ST
Mailing Address - Street 2:SUITE #1H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2086
Mailing Address - Country:US
Mailing Address - Phone:212-222-4700
Mailing Address - Fax:212-222-3035
Practice Address - Street 1:535 W 110TH ST
Practice Address - Street 2:SUITE #1H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2086
Practice Address - Country:US
Practice Address - Phone:212-222-4700
Practice Address - Fax:212-222-3035
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00222606Medicaid
NYB12406Medicare UPIN
NY292241Medicare ID - Type Unspecified