Basic Information
Provider Information
NPI: 1578635090
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CORSO
FirstName: MARK
MiddleName: J
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 37 ROCKFORD RD
Address2:  
City: WILMINGTON
State: DE
PostalCode: 198061003
CountryCode: US
TelephoneNumber: 3027385300
FaxNumber:  
Practice Location
Address1: 4745 OGLETOWN STANTON RD
Address2:  
City: NEWARK
State: DE
PostalCode: 197132067
CountryCode: US
TelephoneNumber: 3027385300
FaxNumber: 3027314822
Other Information
ProviderEnumerationDate: 11/14/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XC1-0006956DEY Other Service ProvidersSpecialist 

ID Information
IDTypeStateIssuerDescription
1000023298005DE MEDICAID


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