Basic Information
| Provider Information | |||||||||
| NPI: | 1326060336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAL CORSO | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 4148 | ||||||||
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| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701784148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 N CAUSEWAY BLVD | ||||||||
| Address2: | DAUGHTERS OF CHARITY HEALTH CENTER | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700015450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044820084 | ||||||||
| FaxNumber: | 5044836018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.07331R | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1367389 | 05 | LA | MEDICAID |