Provider Demographics
NPI:1578507042
Name:CORRALL, CARMEN JAMES II (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:JAMES
Last Name:CORRALL
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:JAMES
Other - Last Name:CORRALL
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:MD1
Mailing Address - Street 1:5700 100TH ST SW STE 510
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2767
Mailing Address - Country:US
Mailing Address - Phone:253-459-6060
Mailing Address - Fax:
Practice Address - Street 1:5700 100TH ST SW STE 510
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2767
Practice Address - Country:US
Practice Address - Phone:253-459-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041929207P00000X, 207Q00000X, 208000000X, 2080P0204X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA897770ZMedicare ID - Type Unspecified
WA500011Medicare ID - Type Unspecified
WAG8904462Medicare PIN
WAA89839Medicare UPIN