Basic Information
| Provider Information | |||||||||
| NPI: | 1053934224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CABALLERO | ||||||||
| FirstName: | CORYNNE | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVENUE ROOM 202 MAIN HOSPITAL | ||||||||
| Address2: | MSC333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 169 ASHLEY AVENUE ROOM 202 MAIN HOSPITAL | ||||||||
| Address2: | MSC333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437921086 | ||||||||
| FaxNumber: | 8437928974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2020 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MMD.84079LL | SC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.