Basic Information
| Provider Information | |||||||||
| NPI: | 1457357378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORALES | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | B | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146073632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855457200 | ||||||||
| FaxNumber: | 5852446456 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146073632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855457200 | ||||||||
| FaxNumber: | 5852446456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
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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 | 207RI0200X | 198349 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 02113404 | 05 | NY | MEDICAID |